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C hapter 19 Assessment and Care of the Newborn KATHRYN RHODES ALDEN LEARNING OBJECTIVES •

C hapter

19

Assessment and Care of the Newborn

KATHRYN RHODES ALDEN

LEARNING OBJECTIVES

Describe the purpose and components of the Apgar score.

Describe the method for estimating the gesta- tional age of a newborn.

Explain the procedure for assessment of the newborn.

Describe common deviations from normal physiologic findings during examination of the newborn.

Discuss nursing care management of the new- born in transition to extrauterine life.

Explain what is meant by a protective environment.

Discuss phototherapy and the guidelines for teaching parents about this treatment.

Explain purposes for and methods of circum- cision, the postoperative care of the circum- cised infant, and parent teaching regarding circumcision.

Describe procedures for doing a heel stick, collecting urine specimens, assisting with venipuncture, and restraining the newborn.

Evaluate pain in the newborn based on physio- logic changes and behavioral observations.

Discuss parent education related to caring for the infant during the first weeks at home.

KEY TERMS AND DEFINITIONS

Apgar score Numeric expression of the condition of a newborn obtained by rapid assessment at 1 and 5 minutes of age; developed by Dr. Virginia Apgar circumcision Excision of the prepuce (foreskin) of the penis, exposing the glans hypothermia Temperature that falls below normal range, that is, below 35° C, usually caused by ex- posure to cold

ophthalmia neonatorum Infection in the neonate’s eyes usually resulting from gonorrheal, chlamydial, or other infection contracted when the fetus passes through the birth canal (vagina) phototherapy Use of lights to reduce serum biliru- bin levels by oxidation of bilirubin into water- soluble compounds that are processed in the liver and excreted in bile and urine

ELECTRONIC RESOURCES

Additional information related to the content in Chapter 19 can be found on

 
the companion website at http://evolve.elsevier.com/Lowdermilk/Maternity/

the companion website at http://evolve.elsevier.com/Lowdermilk/Maternity/

or on the interactive companion CD

the companion website at http://evolve.elsevier.com/Lowdermilk/Maternity/ or on the interactive companion CD

NCLEX Review Questions

NCLEX Review Questions

Case Study—Normal Newborn

Case Study—Normal Newborn

Critical Thinking Exercise—Circumcision

WebLinks

Critical Thinking Exercise—Jaundice

Plan of Care—Normal Newborn

Skill—Changing a Diaper

Skill—Infant Bathing

Skill—Pain Assessment

Video—Assessment of the Newborn

 

559

560

U NIT

S I X

THE NEWBORN

T he numerous biologic changes the neo-

nate makes during the transition to extra-

uterine life are discussed in the preceding

chapter. The first 24 hours are critical be-

cause respiratory distress and circulatory failure can occur rapidly and with little warning. Although most infants make the necessary biopsychosocial adjustment to extrauterine ex- istence without undue difficulty, their well-being depends on the care they receive from others. This chapter describes as- sessment and care of the infant immediately after birth un- til discharge, as well as important parent education related to ongoing infant care. A discussion of pain in the neonate and its management is included.

CARE MANAGEMENT:

FROM BIRTH THROUGH THE FIRST 2 HOURS

Care begins immediately after birth and focuses on assess- ing and stabilizing the newborn’s condition. The nurse has primary responsibility for the infant during this period, be- cause the physician or nurse-midwife is involved with de- livery of the placenta and caring for the mother. The nurse must be alert for any signs of distress and must initiate ap- propriate interventions. With the possibility of transmission of viruses such as hepatitis B virus (HBV) and human immunodeficiency virus (HIV) through maternal blood and blood-stained amniotic fluid, the traditional timing of the newborn’s bath has been questioned. The newborn must be considered a potential contamination source until proved otherwise. As part of Standard Precautions, nurses should wear gloves when han- dling the newborn until blood and amniotic fluid are re- moved by bathing.

until blood and amniotic fluid are re- moved by bathing. Assessment and Nursing Diagnoses The initial

Assessment and Nursing Diagnoses The initial assessment of the neonate is done at birth by us- ing the Apgar score (Table 19-1) and a brief physical exam- ination (Box 19-1). A gestational age assessment is done within 2 hours of birth (Fig. 19-1). A more comprehensive physical assessment is completed within 24 hours of birth (Table 19-2).

TABLE 19-1

Apgar Score

BOX 19-1

Initial Physical Assessment by Body System

CNS

[ ] moves extremities, muscle tone good

[

] symmetric features, movement

[

] suck, rooting, Moro response, grasp reflexes good

[

] anterior fontanel soft and flat

CV

[ ] heart rate strong and regular

[

] no murmurs heard

[

] pulses strong and equal bilaterally

RESP

[ ] lungs clear to auscultation bilaterally

[

] no retractions or nasal flaring

[

] respiratory rate, 30-60 breaths/min

[

] chest expansion symmetric

[

] no upper airway congestion

GU

[ ] male: urethral opening at tip of penis; testes descended bilaterally

[

] female: vaginal opening apparent

GI

[ ] abdomen soft, no distention

[

] cord attached and clamped

[

] anus appears patent

ENT

[ ] eyes clear

[

] palates intact

[

] nares patent

SKIN

Color [ ] pink [ ] acrocyanotic

[

] no lesions or abrasions

[

] no peeling

[

] birthmarks

[

] caput and molding

[

] vacuum “cap”

[

] forceps marks

[ ] other Comments:

Apgar score The Apgar score permits a rapid assessment of the need for resuscitation based on five signs that indicate the phys- iologic state of the neonate: (1) heart rate, based on aus- cultation with a stethoscope; (2) respiratory rate, based on observed movement of the chest wall; (3) muscle tone, based on degree of flexion and movement of the extremities;

SCORE

SIGN

0

1

2

Heart rate

Absent

Slow ( 100)

100

Respiratory rate

Absent

Slow, weak cry

Good cry

Muscle tone

Flaccid

Some flexion of extremities

Well flexed

Reflex irritability

No response

Grimace

Cry

Color

Blue, pale

Body pink, extremities blue

Completely pink

C HAPTER

19

Assessment and Care of the Newborn

561

A
A

Fig. 19-1 Estimation of gestational age. A, New Ballard Scale for newborn maturity rating. Ex- panded scale includes extremely premature infants and has been refined to improve accuracy in more mature infants. (From Ballard, J. et al. [1991]. New Ballard Score, expanded to include ex- tremely premature infants. Journal of Pediatrics, 119[3], 417-423.)

Continued

(4) reflex irritability, based on response to gentle slaps on the soles of the feet; and (5) generalized skin color, described as pallid, cyanotic, or pink. Each item is scored as a 0, 1, or 2. Evaluations are made 1 and 5 minutes after birth. Scores of 0 to 3 indicate severe distress; scores of 4 to 6 indicate moderate difficulty; and scores of 7 to 10 indicate that the infant is having no difficulty adjusting to extrauterine life. Apgar scores do not predict future neurologic outcome but are useful for describing the newborn’s transition to extrauterine environment (Box 19-2). Should resuscita- tion be required, it should be initiated before the 1-minute Apgar score (American Academy of Pediatrics [AAP] and American College of Obstetricians and Gynecologists [ACOG], 2002).

Initial Physical Assessment

The initial physical assessment includes a brief review of systems (see Box 19-1):

1. External: Note skin color, general activity, position; as- sess nasal patency by covering one nostril at a time while observing respirations; skin: peeling, or lack of subcu- taneous fat (dysmaturity or postterm); note meconium staining of cord, skin, fingernails, or amniotic fluid (stain- ing may indicate fetal release of meconium, often related to hypoxia; offensive odor may indicate intrauterine in- fection); note length of nails and creases on soles of feet.

2. Chest: Auscultate apical heart for rate and rhythm, heart tones and presence of abnormal sounds; note character of respirations and presence of crackles or

562 U NIT S I X THE NEWBORN CLASSIFICATION OF NEWBORNS— BASED ON MATURITY AND
562
U NIT
S I X
THE NEWBORN
CLASSIFICATION OF NEWBORNS—
BASED ON MATURITY AND INTRAUTERINE GROWTH
Symbols:
X - 1st Examination O - 2nd Examination
CM
CM
53
37
90%
90%
52
36
51
35
HEAD
CIRCUM-
LENGTH
50%
50
cm 50%
34
FERENCE
cm
49
33
48
32
10%
47
31
46
10%
30
45
29
44
28
43
27
42
26
41
25
40
24
39
23
38
22
37
0
36
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
35
WEEK OF GESTATION
34
33
B
32
31

GM

4200

4000

3800

3600

3400

3200

3000

2800

2600

2400

2200

2000

1800

1600

1400

1200

1000

800

600

400

0

24

25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

WEEK OF GESTATION 1st Examination 2nd Examination (X) (O) 24 25 26 27 28 29
WEEK OF GESTATION
1st Examination
2nd Examination
(X) (O)
24
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
LARGE
FOR
GESTATIONAL
WEIGHT
gm
AGE
(LGA)
90%
APPROPRIATE
FOR
50%
GESTATIONAL
AGE
(AGA)
10%
SMALL
FOR
GESTATIONAL
AGE
(SGA)
Age at Examination
hrs
hrs
Signature
of
Examiner
M.D.
M.D.
PRETERM
TERM
POSTTERM

Fig. 19-1, cont’d

rity and intrauterine growth. (Modified from Lubchenco, L., Hansman, C., & Boyd, E. [1966]. Intra- uterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks. Journal of Pediatrics, 37[3], 403-408; and Battaglia, F., & Lubchenco, L. [1967]. A practical classification of newborn infants by weight and gestational age. Journal of Pediatrics, 71[2], 159-167.)

Estimation of gestational age. B, Newborn classification based on matu-

other adventitious sounds; note equality of breath sounds by auscultation. 3. Abdomen: Observe characteristics of abdomen (rounded, flat, concave) and absence of anomalies; aus- cultate bowel sounds; note number of vessels in cord. 4. Neurologic: Check muscle tone; assess Moro and suck reflexes; palpate anterior fontanel; note by palpation the presence and size of the fontanels and sutures.

5. Genitourinary: Note external sex characteristics and any abnormality of genitalia; check anal patency, presence of meconium; note passage of urine.

6. Other observations: Note gross structural malformations

obvious at birth that may require immediate medical attention. The nurse responsible for the care of the newborn im- mediately after birth verifies that respirations have been

Text continued on p. 575.

CD: Video—Assessment of the Newborn

TABLE 19-2

Physical Assessment of Newborn

C HAPTER

19

Assessment and Care of the Newborn

563

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

POSTURE

Inspect newborn before dis-

Vertex: arms, legs in moder-

Hypotonia

Prematurity or hypoxia in

turbing Refer to maternal chart for fetal presentation, posi-

ate flexion; fists clenched Normal spontaneous move- ment bilaterally asynchro-

Hypertonia

utero, maternal medica- tions Drug dependence, central

tion, and type of birth (vaginal, surgical), be- cause newborn readily assumes prenatal position

nous but equal extension in all extremities Frank breech: legs straighter and stiff

Opisthotonos Limitation of motion in any of extremities (see p. 573)

nervous system (CNS) disorder CNS disturbance

VITAL SIGNS

Heart rate and pulses:

Visible pulsations in left

Ta chycardia: persistent,

Respiratory distress

Pneumomediastinum

Inspection

midclavicular line, fifth in-

180 beats/min

syndrome (RDS)

Palpation

tercostal space

Bradycardia: persistent,

Congenital heart block, ma-

Auscultation

Apical pulse, fourth inter-

80 beats/min

ternal lupus

costal space 100-160 beats/min 80-100 beats/min (sleeping)

Murmurs Arrhythmias: irregular rate Sounds distant,

Possibly functional

to 180 beats/min (crying) Quality: first sound (closure of mitral and tricuspid valves) and second sound (closure of aortic and pul- monic valves) sharp and clear Possible murmur

poor quality, extra Heart on right side of chest

Dextrocardia, often accom- panied by reversal of in- testines

Peripheral pulses:

femoral, brachial, popliteal, posterior tibial

Peripheral pulses equal and strong Femoral pulses equal and strong

Weak or absent peripheral

Weak or absent femoral pulses; unequal

Decreased cardiac output, thrombus Hip dysplasia, coarctation of aorta if weak on left and strong on right, throm- bophlebitis

Temperature

Axillary: 36.5° C to 37.2° C Temperature stabilized by 8-10 hr of age

Subnormal

Prematurity, infection, low environmental tempera- ture, inadequate clothing,

 

Increased

dehydration Infection, high environmen-

Temperature not stabilized by 6-8 hr after birth

tal temperature, exces- sive clothing, proximity to heating unit or in direct sunshine, drug addiction, diarrhea and dehydration If mother received magne- sium sulfate, maternal

Check respiratory rate and

30-60 breaths/min

Apneic episodes: 15 sec

analgesics Preterm infant: “periodic

effort when infant is at rest Count respirations for full minute

Shallow and irregular in rate, rhythm, and depth when infant is awake Crackles may be heard after birth

Bradypnea: 25/min

breathing,” rapid warm- ing or cooling of infant Maternal narcosis from analgesics or anesthetics, birth trauma

Continued

rapid warm- ing or cooling of infant Maternal narcosis from analgesics or anesthetics, birth trauma Continued

564

U NIT

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TABLE 19-2

THE NEWBORN

Physical Assessment of Newborn—cont’d

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

VITAL SIGNS—cont’d

Measure blood pressure (BP) using oscillometric monitor BP cuff; palpate brachial, popliteal, or pos- terior tibial pulse (de- pending on measurement site) Check electronic monitor BP cuff: BP cuff width af- fects readings, use cuff 2.5 cm wide and palpate radial pulse

WEIGHT*

Breath sounds loud, clear, near

80-90s/40s-50s

Ta chypnea: 60/min

Crackles, rhonchi, wheezes Expiratory grunt Distress evidenced by nasal flaring, retractions, chin tug, labored breathing Difference between upper and lower extremity pressures Hypotension Hypertension

RDS, congenital diaphrag- matic hernia, transient tachypnea of the newborn Fluid in lungs

Narrowing of bronchi RDS, fluid in lungs

Coarctation of aorta

Sepsis, hypovolemia Coarctation of aorta, renal involvement, thrombus

Weigh at same time each day

2500-4000 g Acceptable weight loss:

Weight 2500 g

Prematurity, small for gestational age, rubella

10% Second baby weighs more than first Birth weight regained within first 2 weeks

Weight 4000 g

syndrome Large for gestational age, maternal diabetes, heredity—normal for these parents

 

Weight loss 10% to 15%

Dehydration

  We ight loss 1 0% to 15% Dehydration W eighing the infant. Note that a

Weighing the infant. Note that a hand is held over the infant as a safety measure. The scale is covered to protect against cross-infection. (Courtesy Kim Molloy, Knoxville, IA.)

*Note: Weight, length, and head circumference all should be close to the same percentile for any newborn.

TABLE 19-2

C HAPTER

19

Physical Assessment of Newborn—cont’d

Assessment and Care of the Newborn

565

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

LENGTH

Length from top of head to heel

45-55 cm

45 cm or 55 cm

Chromosomal abnormality, heredity—normal for these parents

Chromosomal abnormality, heredity—normal for these parents L ength, crown to rump. To determine total length, include

L ength, crown to rump. To determine total length, include length of legs. If measurements are taken before the infant’s initial bath, wear gloves. (Courtesy Marjorie Pyle, RNC, Life- circle, Costa Mesa, CA.)

HEAD CIRCUMFERENCE

Measure head at greatest diameter: occipitofrontal circumference

32-36.8 cm Circumference of head and chest approximately the same for first 1 or 2 days after birth

Small head 32 cm: micro- cephaly

Hydrocephaly: sutures widely separated, circum- ference 4 cm more than chest circumference Increased intracranial pressure

Maternal rubella, toxoplas- mosis, cytomegalic inclu- sion disease, fused cranial sutures (craniosynostosis) Maldevelopment, infection

Hemorrhage, space-

occupying lesion

infection Hemorrhage, space- occupying lesion Circumference of head. (Courtesy Marjorie Pyle, RNC, Life-

Circumference of head. (Courtesy Marjorie Pyle, RNC, Life- circle, Costa Mesa, CA.)

Continued

566

U NIT

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TABLE 19-2

THE NEWBORN

Physical Assessment of Newborn—cont’d

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

CHEST CIRCUMFERENCE

Measure at nipple line

2-3 cm less than head cir- cumference, averages be- tween 30 and 33 cm

30 cm

Prematurity

averages be- tween 30 and 33 cm 30 cm P rematurity ABDOMINAL CIRCUMFERENCE Measure above umbilicus

ABDOMINAL CIRCUMFERENCE

Measure above umbilicus Not usually measured un- less specific indication

Same size as chest

Circumference of chest. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

Enlarging abdomen be- tween feedings

Abdominal mass or block- age in intestinal tract

feedings Abdominal mass or block- age in intestinal tract SKIN Abdominal circumference. (Courtesy Marjorie Pyle, RNC,

SKIN

Abdominal circumference. (Courtesy Marjorie Pyle, RNC, Lifecir- cle, Costa Mesa, CA.)

Color

Generally pink

Dark red

Prematurity, polycythemia

Varying with ethnic origin

Gray

Hypotension, poor

Acrocyanosis, especially if chilled

Pallor

perfusion Cardiovascular problem,

Mottling Harlequin sign Plethora Telangiectases (“stork bites” or capillary heman- giomas) Erythema toxicum or neonatorum (“newborn rash”) Milia

Cyanosis

CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, nosocomial infection Hypothermia, infection, hy- poglycemia, cardiopul- monary diseases, cardiac, neurologic, or respiratory malformations

TABLE 19-2

C HAPTER

19

Physical Assessment of Newborn—cont’d

Assessment and Care of the Newborn

567

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

SKIN—cont’d

 

Petechiae over presenting part Ecchymoses from forceps in vertex births or over but- tocks, genitalia, and legs in breech births

Mongolian spot (see Fig.

Petechiae over any other area Ecchymoses in any other area

Clotting factor deficiency, infection Hemorrhagic disease, trau- matic birth

Jaundice

None at birth Physiologic jaundice in up to 50% of term infants in

Jaundice within first 24 hr

Increased hemolysis, Rh isoimmunization, ABO incompatibility

Birthmarks

first week of life

18-6)

Hemangiomas Nevus flammeus: port-

Infants of African- American, Asian, and Native American origin:

wine stain Nevus vasculosus: straw- berry mark

70%-85%

Cavernous hemangiomas

Check condition

Infants of Caucasian origin: 5%-13% No skin edema

Edema on hands, feet; pit-

Overhydration

Opacity: few large blood vessels visible indistinctly over abdomen

ting over tibia Texture thin, smooth, or of medium thickness; rash or superficial peeling

Prematurity, postmaturity

 

visible Numerous vessels very visi-

Prematurity

ble over abdomen Texture thick, parchment-

Postmaturity

Gently pinch skin between thumb and forefinger over abdomen and inner thigh to check for turgor

Dehydration: loss of weight best indicator After pinch released, skin returns to original state

like; cracking, peeling Skin tags, webbing Papules, pustules, vesicles, ulcers, maceration Loose, wrinkled skin

Impetigo, candidiasis, herpes, diaper rash Prematurity, postmaturity, dehydration: fold of skin persisting after release of pinch

immediately

Te nse, tight, shiny skin

Edema, extreme cold,

Vernix caseosa:

Normal weight loss after birth: 10% of birth weight Possibly puffy Whitish, cheesy, odorless;

Lack of subcutaneous fat, prominence of clavicle or ribs Absent or minimal

shock, infection Prematurity, malnutrition

Color and odor

usually more found in creases, folds

Excessive Green color

Postmaturity Prematurity Possible in utero release of

 

Odor

meconium or presence of bilirubin Possible intrauterine infection

Lanugo

Over shoulders, pinnas of

Absent

Postmaturity

ears, forehead

Excessive

Prematurity, especially if lanugo abundant and long and thick over back

Continued

568

U NIT

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TABLE 19-2

THE NEWBORN

Physical Assessment of Newborn—cont’d

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

HEAD

 

Making up one fourth of

Posterior fontanel triangle,

Cephalhematoma

body length

Molding

Molding

Severe molding

Birth trauma

Caput succedaneum, possi- bly showing some ecchy- mosis

Indentation

Fracture from trauma Tumor, hemorrhage, infection

Fontanels Open vs closed

Anterior fontanel 5 cm dia- mond, increasing as

Full, bulging Large, flat, soft

Malnutrition, hydrocephaly, retarded bone age, hy-

molding resolves

smaller than anterior

Depressed

pothyroidism Dehydration

Sutures

Palpable and unjoined su-

Widely spaced

Hydrocephaly

tures Possible overlap of sutures with molding

Premature closure

Craniosynostosis

Hair

Silky, single strands lying flat; growth pattern to- ward face and neck, varia- tion in amount

Fine, woolly Unusual swirls, patterns, hairline or coarse, brittle

Prematurity Endocrine or genetic disorders

EYES

Eyeballs

Both present and of equal size, both round, firm Eyes and space between eyes each one third the

No discharge

Agenesis or absence of one or both eyeballs Epicanthal folds when pres- ent with other signs

Chromosomal disorders such as Down, cri-du-chat

distance from outer-to- outer canthus

Discharge: purulent

syndromes Infection

Epicanthal folds: normal racial characteristic Symmetric in size, shape Blink reflex

Small eyeball Lens opacity or absence of red reflex Discharge (purulent)

Lesions: coloboma, absence

Rubella syndrome Congenital cataracts, possi- bly from rubella Infection

Albinism

No tears Subconjunctival hemor- rhage

Chemical conjunctivitis

of part of iris Pink color of iris

Eye medication (requires no treatment) Congenital

 

Jaundiced sclera

Hyperbilirubinemia

  J aundiced sclera Hyperbilirubinemia Eyes. In pseudostrabismus, inner epicanthal folds cause the

Eyes. In pseudostrabismus, inner epicanthal folds cause the eyes to appear misaligned; however, corneal light reflexes are perfectly symmetric. Eyes are symmetric in size and shape and are well placed.

TABLE 19-2

C HAPTER

19

Physical Assessment of Newborn—cont’d

Assessment and Care of the Newborn

569

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

EYES—cont’d

Pupils

Present, equal in size, reac- tive to light

Pupils: unequal, constricted, dilated, fixed

Intracranial pressure, med- ications, tumors

Eyeball movement

Random, jerky, uneven, fo- cus possible briefly, fol-

Persistent strabismus Doll’s eyes

Increased intracranial

lowing to midline Transient strabismus or nys- tagmus until third or fourth month

Sunset

pressure Increased intracranial pressure

Eyebrows

Distinct (not connected in

Connection in midline

Cornelia de Lange syndrome

NOSE

midline)

Midline Some mucus but no

Copious drainage, with or without regular periods of

Flaring of nares

Choanal atresia, congenital syphilis

drainage Preferential nose breather Sneezing to clear nose Slight deformity (flat or de- viated to one side) from passage through birth

cyanosis at rest and re- turn of pink color with crying Malformed

Congenital syphilis, chromosomal disorder Respiratory distress

EARS

canal

Pinna

Correct placement: line drawn through inner and outer canthi of eyes reaching to top notch of ears (at junction with

Agenesis Lack of cartilage Low placement

Prematurity Chromosomal disorder, mental retardation, kid- ney disorder

scalp) Well-formed, firm cartilage

Preauricular tags Size: possibly overly promi-

Hearing

Responds to voice and other sounds State (e.g., alert, asleep) influences response

nent or protruding ears No response to sound

Deaf, rubella syndrome

A

ears No response to sound Deaf, rubella syndrome A B C Placement of ears on the

B

ears No response to sound Deaf, rubella syndrome A B C Placement of ears on the

C

ears No response to sound Deaf, rubella syndrome A B C Placement of ears on the

Placement of ears on the head in relation to a line drawn from the inner to the outer canthus of the eye. A, Normal position. B, Abnormally angled ear. C,True low-set ear. (Courtesy Mead John- son Nutritionals, Evansville, IN.)

Continued

570

U NIT

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TABLE 19-2

THE NEWBORN

Physical Assessment of Newborn—cont’d

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

FACIES

 

“Normal” appearance, well- placed, proportionate, symmetric features Positional deformities

Infant appearance “odd” or “funny” Usually accompanied by other features such as low-set ears, other struc- tural disorders

Hereditary, chromosomal aberration

MOUTH

Lips

Symmetry of lip movement

Transient circumoral

Gross anomalies in place-

Asymmetry in movement of

Cleft lip and/or palate, gums

Buccal mucosa

Dry or moist Pink

cyanosis

ment, size, shape Cyanosis, circumoral pallor

lips

Respiratory distress, hy- pothermia Cranial nerve VII paralysis

Gums

Pink gums Inclusion cysts (Epstein pearls—Bohn nodules, whitish, hard nodules on gums or roof of mouth)

Teeth: predeciduous or deciduous

Hereditary

Tongue

Tongue not protruding, freely movable, symmet- ric in shape, movement Sucking pads inside cheeks

Macroglossia Short lingual frenulum Thrush: white plaques on cheeks or tongue that bleed if touched

Prematurity, chromosomal disorder Candida albicans

Palate (soft, hard):

Soft and hard palates intact

Cleft hard or soft palate

Arch

Uvula

Uvula in midline Epstein pearls

Chin

Distinct chin

Micrognathia

Pierre Robin or other syndrome

Saliva

Mouth moist

Excessive saliva

Esophageal atresia, tra-

Reflexes:

Reflexes present

Absent

cheoesophageal fistula Prematurity

Rooting

Reflex response dependent

Sucking

on state of wakefulness

Extrusion

and hunger

NECK

Sternocleidomastoid

muscles

Thyroid gland

CHEST

Thorax

Short, thick, surrounded by skin folds; no webbing Head held in midline (ster- nocleidomastoid muscles equal), no masses Transient positional deformity Freedom of movement from side to side and flexion and extension, no move- ment of chin past shoulder Thyroid not palpable

Almost circular, barrel shaped Tip of sternum possibly prominent

Webbing Restricted movement, hold- ing of head at angle Absence of head control

Masses

Distended veins

Bulging of chest, unequal movement Malformation

Turner syndrome To rticollis (wryneck), opisthotonos Prematurity, Down syn- drome

Enlarged thyroid Cardiopulmonary disorder

Pneumothorax, pneumo- mediastinum Funnel chest—pectus excavatum

TABLE 19-2

C HAPTER

19

Physical Assessment of Newborn—cont’d

Assessment and Care of the Newborn

571

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

CHEST—cont’d

Respiratory movements

Symmetric chest move- ments, chest and abdomi-

Retractions with or without respiratory distress

Prematurity, RDS

Clavicles

nal movements synchro- nized during respirations Occasional retractions, es- pecially when crying Clavicles intact

Trauma

Ribs

Rib cage symmetric, intact;

Fracture of clavicle; crepitus Poor development of rib

Prematurity

Nipples

moves with respirations Prominent, well formed; symmetrically placed

cage and musculature Supernumerary, along nip- ple line Malpositioned or widely

Breast tissue

Breast nodule: approximately 3-10 mm in term infant Maternal hormones Secretion of witch’s milk

spaced Lack of breast tissue

Prematurity

ABDOMEN

Umbilical cord

Two arteries, one vein Whitish gray Definite demarcation be-

One artery Meconium stained Bleeding or oozing around

Renal anomalies Intrauterine distress Hemorrhagic disease

tween cord and skin, no intestinal structures within cord Dry around base, drying Odorless Cord clamp in place for 24 hr Reducible umbilical hernia

cord Redness or drainage around cord Herniation of abdominal contents into area of cord (e.g., omphalocele); de- fect covered with thin, fri- able membrane, possibly extensive

Infection, possible persis- tence of urachus

Abdomen

Rounded, prominent, dome shaped because abdomi-

Gastroschisis: fissure of ab- dominal cavity

nal musculature not fully developed Some diastasis of abdomi- nal musculature Liver possibly palpable 1-2 cm below right costal margin No other masses palpable No distention

Distention at birth

 

Mild

Ruptured viscus, genitouri- nary masses or malforma- tions: hydronephrosis, ter- atomas, abdominal tumors Overfeeding, high gastroin-

Infection

Marked

testinal tract obstruction Lower gastrointestinal tract

Intermittent or transient Partial intestinal obstruction Visible peristalsis Malrotation of bowel or ad- hesions Sepsis

obstruction, imperforate anus Overfeeding Stenosis of bowel Obstruction

Continued

572

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TABLE 19-2

THE NEWBORN

Physical Assessment of Newborn—cont’d

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

ABDOMEN—cont’d

Bowel sounds

Sounds present within minutes after birth in healthy term infants

Scaphoid, with bowel sounds in chest and respi- ratory distress

Diaphragmatic hernia

Stools

Meconium stool passing

No stool

Imperforate anus

Color

within 24-48 hr after birth Linea nigra possibly apparent

Hormone influence during pregnancy

Movement with respiration

Respirations primarily di- aphragmatic, abdominal and chest movement syn- chronous

Decreased abdominal breathing “Seesaw”

Intrathoracic disease, phrenic nerve palsy, di- aphragmatic hernia Respiratory distress

GENITALIA

Female

Female genitals

Ambiguous genitals— enlarged clitoris with uri-

Chromosomal disorder, ma- ternal drug ingestion

Clitoris

Usually edematous

nary meatus on tip, fused labia Virilized female; extremely

Congenital adrenal hyper-

Labia majora

Usually edematous, cover- ing labia minora in term newborns

large clitoris

plasia

Labia minora

Increased pigmentation Edema and ecchymosis Possible protrusion over labia majora

Labia majora widely sepa- rated and labia minora prominent

Pregnancy hormones Breech birth Prematurity

Discharge

Smegma

Vagina

Open orifice Some vernix caseosa be- tween labia possible

Absence of vaginal orifice

Blood-tinged discharge

Fecal discharge

Fistula

from pseudomenstrua- tion caused by pregnancy hormones Mucoid discharge Hymenal or vaginal tag

Stenosed meatus

Urinary meatus

Beneath clitoris, difficult to see (to watch for void- ing)

Bladder extrophy

Male

Male genitals

Increased size and pigmen-

Ambiguous genitals

Penis

tation caused by preg- nancy hormones

Urinary meatus as slit Prepuce

Meatus at tip of penis Prepuce (foreskin) covering glans penis and not re- tractable

Urinary meatus not on tip of glans penis Prepuce removed if circum- cised Wide variation in size of genitals

Hypospadias, epispadias Round meatal opening

TABLE 19-2

C HAPTER

19

Physical Assessment of Newborn—cont’d

Assessment and Care of the Newborn

573

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

GENITALIA—cont’d

Male—cont’d

Scrotum

Large, edematous, pendu-

Scrotal edema and ecchy-

Rugae (wrinkles)

lous in term infant; cov-

mosis if breech birth

ered with rugae

Scrotum smooth and testes

Prematurity, cryptorchidism

 

undescended Hydrocele, small, noncom- municating Inguinal hernia Bulge palpable in inguinal

Prematurity

Testes

Palpable on each side

canal Undescended

Check urination

Voiding within 24 hr, stream

Uric acid crystals*

Check reflex

adequate, amount ade- quate Rust-stained urine

Cremasteric

Testes retracted, especially when newborn is chilled

EXTREMITIES

Degree of flexion Range of motion Symmetry of motion

Assuming of position main- tained in utero Transient (positional) defor-

Limited motion Poor muscle tone

Malformations Prematurity, maternal med- ications, CNS anomalies

mities Attitude of general flexion

Positive scarf sign Asymmetry of movement

Fracture or crepitus,

Muscle tone

Full range of motion, spon-

brachial nerve trauma,

Arms and hands Intactness Appropriate placement

taneous movements Longer than legs in new- born period Contours and movement

Asymmetry of contour Amelia or phocomelia Palmar creases

malformations Malformations, fracture Teratogens

symmetric

Simian line with short, in-

Down syndrome

Color

Slight tremors sometimes apparent Some acrocyanosis, espe- cially when chilled

curved little fingers

Fingers

Five on each hand

Webbing of fingers: syn-

Familial trait

Fist often clenched with thumb under fingers

dactyly Absence or excess of fingers Strong, rigid flexion; per-

CNS disorder

 

sistent fists; positioning of fists in front of mouth constantly Increased tonicity, clonus,

CNS disorder

Joints Grasp (palmar and plantar) Humerus Legs and feet

Full range of motion, sym- metric contour Intact Appearance of bowing be- cause lateral muscles more developed than me- dial muscles

prolonged tremors Fractured humerus Amelia (absence of limbs), phocomelia (shortened limbs)

Trauma Chromosomal deficiency, teratogenic effect

Feet appearing to turn in but can be easily rotated externally, positional de- fects tending to correct while infant is crying Acrocyanosis

Te mperature of one leg dif- ferent from that of the other

Circulatory deficiency CNS disorder

*To determine whether rust color is caused by uric acid or blood, rinse diaper under running warm tap water; uric acid washes out, blood does not.

574

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TABLE 19-2

THE NEWBORN

Physical Assessment of Newborn—cont’d

AREA ASSESSED

NORMAL FINDINGS

DEVIATIONS FROM NORMAL RANGE

ETIOLOGY

EXTREMITIES—cont’d

Toes

Five on each foot

Webbing, syndactyly Absence or excess of digits

Chromosomal defect Chromosomal defect, famil-

Femur

Intact femur No click heard, femoral head not overriding ac-

Femoral fracture Developmental dysplasia or dislocation

ial trait Difficult breech birth

Soles of feet

etabulum Major gluteal folds even Soles well lined (or wrin-

Soles of feet

kled) over two thirds of

Few lines

Prematurity

foot in term infants Plantar fat pad giving flat- footed effect

Covered with lines Congenital clubfoot

Postmaturity

Joints

Full range of motion, sym- metric contour

Hypermobility of joints Asymmetric movement

Down syndrome Trauma, CNS disorder

BACK

Spine

Spine straight and easily flexed

Limitation of movement

Fusion or deformity of ver- tebra

Shoulders

Infant able to raise and sup-

Scapulae

port head momentarily

Iliac crests

when prone Temporary minor positional deformities, correction with passive manipula- tion Shoulders, scapulae, and il- iac crests lining up in same plane

Base of spine—pilonidal area

Spina bifida cystica

Meningocele, myelomeningocele

Pigmented nevus with tuft of hair

Often associated with spina bifida occulta

ANUS

Patency Sphincter response (active “wink” reflex)

STOOLS

Frequency, color, consis- tency

One anus with good sphinc- ter tone Passage of meconium within 24-48 hr after birth Good “wink” reflex of anal sphincter

Meconium followed by tran- sitional and soft yellow stools

Low obstruction: anal mem- brane High obstruction: anal or rectal atresia Absence of anal opening Drainage of fecal material from vagina in female or urinary meatus in male

No stool Frequent watery stools

Rectal fistula

Obstruction Infection, phototherapy

BOX 19-2

C HAPTER

19

Significance of the Apgar Score

The Apgar score was developed to provide a systematic method of assessing an infant’s condition at birth. Re- searchers have tried to correlate Apgar scores with var- ious outcomes such as development, intelligence, and neurologic development. In some instances, researchers have attempted to attribute causality to the Apgar score, that is, to suggest that the low Apgar score caused or pre- dicted later problems.This is an inappropriate use of the Apgar score. Instead the score should be used to ensure that infants are systematically observed at birth to as- certain the need for immediate care. Either a physician or a nurse may assign the score; however, to avoid the real or perceived appearance of bias, the person assisting with the birth should not assign the score. Lack of con- sistency in the assigned scores limits studies of the Ap- gar’s long-term predictive value. Prospective parents and the public need education on the significance of the Ap- gar score, as well as its limits. Because infants often do not receive the maximum score of 10, parents need to know that scores of 7 to 10 are within normal limits. At- torneys involved in litigation related to injury of an infant at birth or negative outcomes, either short term or long term, also need education about the Apgar score, its sig- nificance, and its limits.This useful tool needs to be used appropriately; health care providers, parents, and the public may need education to ensure appropriate use of the score.

Data from Montgomery, K. (2000). Apgar scores: Examining the long- term significance. Journal of Perinatal Education, 9(3), 5-9.

established, dries the infant, assesses temperature, and places identical identification bracelets on the infant and the mother. In some settings, the father or partner also wears an identification bracelet. The infant may be wrapped in a warm blanket and placed in the arms of the mother, given to the partner to hold, or kept partially undressed under a radiant warmer. In some settings, immediately after birth the infant

is placed on the mother’s abdomen to allow skin-to-skin con-

tact. This contributes to maintenance of the infant’s opti- mum temperature and parental bonding. The infant may be admitted to a nursery or may remain with the parents throughout the hospital stay. The initial examination of the newborn can occur while the nurse is drying and wrapping the infant, or observations can be made while the infant is lying on the mother’s abdomen or in her arms immediately after birth. Efforts should be di- rected to minimizing interference in the initial parent-infant acquaintance process. If the infant is breathing effectively, is

pink in color, and has no apparent life-threatening anomalies

or risk factors requiring immediate attention (e.g., infant of

a diabetic mother), further examination can be delayed un-

til after the parents have had an opportunity to interact with the infant. Routine procedures and the admission process can be carried out in the mother’s room or in a separate nursery. Box 19-3 shows an example of newborn routine orders.

Assessment and Care of the Newborn

BOX 19-3

575

Routine Admission Orders

Vital signs on admission and q30min 2, q1hr 2, then q8hr

Weight, length, and head and chest circumference on admission; then weigh daily

Tetracycline or erythromycin ophthalmic ointment 5 mg 1 to 2 cm line in lower conjunctiva of each eye after initial parent-infant contact (but within 2 hr of birth)

Vitamin K 0.5 to 1 mg intramuscularly

Breastfeeding on demand may be initiated immedi- ately after birth

If formula feeding, give formula of mother’s choice q3-4 hr on demand

Allow rooming-in as desired and infant’s condition permits

Newborn screening panel per state health depart- ment protocol (phenylketonuria [PKU], thyroxine [T 4 ], and galactosemia or other newborn screening tests as ordered at least 24 hr after first feeding)

Perform hearing screening and document results before discharge

Serum bilirubin measurement if clinical jaundice evident

Hepatitis B injection if indicated

Nursing diagnoses are established after analysis of the findings of the physical assessment and may include the fol- lowing:

Ineffective airway clearance related to —airway obstruction with mucus, blood, and am- niotic fluid

Impaired gas exchange related to —airway obstruction

Ineffective thermoregulation related to —excess heat loss

Risk for infection related to —intrauterine or extrauterine exposure to virulent virus or bacteria —multiple sites for opportunistic bacterial and vi- ral entry (e.g., umbilical cord, lesions from fetal scalp electrode or vacuum extraction)

Expected Outcomes of Care Expected outcomes can apply to both the infant and the caregiver. The expected outcomes for the newborn during the immediate recovery period include that the infant will achieve the following:

Maintain effective breathing pattern

Maintain effective thermoregulation

Remain free from infection

Receive necessary nutrition for growth Expected outcomes for the parents include that they will do the following:

Attain knowledge, skill, and confidence relevant to in- fant care activities

576

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Procedure

THE NEWBORN

Suctioning with a Bulb Syringe

The mouth is suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are touched. The bulb is compressed (see Fig. 19-2) and inserted into one side of the mouth.The center of the infant’s mouth is avoided because this could stimulate the gag reflex. The nasal passages are suctioned one nostril at a time. When the infant’s cry does not sound as though it is through mucus or a bubble, suctioning can be stopped.The bulb syringe should always be kept in the infant’s crib. The parents should be given demonstrations on how to use the bulb syringe and asked to perform a return demonstration.

State understanding of biologic and behavioral char- acteristics of the newborn

Begin to integrate the infant into the family

Plan of Care and Interventions Changes can occur rapidly in newborns immediately after birth. Assessment must be followed quickly by the imple- mentation of appropriate care.

Identification Information on the matching identification bracelets ap- plied immediately after birth to the newborn and mother (and in some institutions, the father or significant other) should include name, sex, date and time of birth, and iden- tification number, according to hospital protocol. Infants also are footprinted by using a form that includes the mother’s fingerprints, name, and date and time of birth. These identification procedures must be performed before the mother and infant are separated after birth.

Stabilization Generally, the normal term infant born vaginally has lit- tle difficulty clearing the airway. Most secretions are moved by gravity and brought to the oropharynx by the cough re- flex. The infant is often maintained in a side-lying position (head stabilized, not in Trendelenburg) with a rolled blan- ket at the back to facilitate drainage. If the infant has excess mucus in the respiratory tract, the mouth and nasal passages may be suctioned with the bulb syringe (Procedure box and Fig. 19-2). The nurse may per- form gentle percussion over the chest wall using a soft cir- cular mask or a percussion cup to aid in loosening secretions before suctioning (Fig. 19-3). Routine chest percussion is avoided, especially in preterm newborns, because this may cause more harm than good; the head should be kept steady during the procedure and the infant’s tolerance to the pro- cedure carefully evaluated (Hagedorn, Gardner, & Abman,

Fig. 19-2 Bulb syringe. Bulb must be compressed before insertion.
Fig. 19-2
Bulb syringe. Bulb must be compressed before
insertion.
Bulb syringe. Bulb must be compressed before insertion. F ig. 19-3 Chest percussion. Nurse performs gentle

Fig. 19-3 Chest percussion. Nurse performs gentle per- cussion over the chest wall by using a percussion cup to aid in loosening secretions before suctioning. (Courtesy Shannon Perry, Phoenix, AZ.)

2002). The infant who is choking on secretions should be supported with the head to the side. The mouth is suctioned first to prevent the infant from inhaling pharyngeal secre- tions by gasping as the nares are touched. The bulb is com- pressed and inserted into one side of the mouth. The cen- ter of the mouth is avoided because this could stimulate the gag reflex. The nasal passages are suctioned one nostril at a time. The bulb syringe should always be kept in the infant’s crib. The parents should be given a demonstration of how to use the bulb syringe and asked to perform a return demon- stration. Use of nasopharyngeal catheter with me- chanical suction apparatus. Deeper suctioning may be needed to remove mucus from the newborn’s na- sopharynx or posterior oropharynx. Proper tube insertion and suctioning for 5 seconds or less per tube insertion helps prevent vagal stimulation and hypoxia (Niermeyer, 2005) (Procedure box). Relieving airway obstruction. A choking infant needs immediate attention. Often, simply repositioning the infant and suctioning the mouth and nose with the bulb sy-

Procedure

C HAPTER

19

Suctioning with a Nasopharyngeal Catheter with Mechanical Suction Apparatus

To remove excessive or tenacious mucus from the infant’s nasopharynx:

If wall suction is used, adjust the pressure to 80 mm Hg. Proper tube insertion and suctioning for 5 sec per tube insertion help prevent laryn- gospasms and oxygen depletion. Lubricate the catheter in sterile water and then insert either orally along the base of the tongue or up and back into the nares. After the catheter is properly placed, create suction by placing your thumb over the control as the catheter is carefully rotated and gently withdrawn. Repeat the procedure until the infant’s cry sounds clear and air entry into the lungs is heard by stethoscope.

ringe eliminates the problem. The infant should be posi- tioned with the head slightly lower than the body to facili- tate gravity drainage. The nurse also should listen to the in- fant’s respiration and lung sounds with a stethoscope to determine whether there are crackles, rhonchi, or inspiratory stridor. Fine crackles may be auscultated for several hours af- ter birth. If air movement is adequate, the bulb syringe may be used to clear the mouth and nose. If the bulb syringe does not clear mucus interfering with respiratory effort, me- chanical suction can be used. If the newborn has an obstruction that is not cleared with suctioning, further investigation must be performed to de- termine if there is a mechanical defect (e.g., tracheo- esophageal fistula, choanal atresia) causing the obstruction (see Emergency: Relieving Airway Obstruction, p. 612). Maintaining an adequate oxygen supply. Four conditions are essential for maintaining an adequate oxygen supply:

A clear airway

Effective establishment of respirations

Adequate circulation, adequate perfusion, and effec- tive cardiac function

Adequate thermoregulation (exposure to cold stress in- creases oxygen and glucose needs) Signs of potential complications related to abnormal breathing are listed in the Signs of Potential Complications box.

Maintenance of body temperature Effective neonatal care includes maintenance of an op- timal thermal environment. Cold stress increases the need for oxygen and may deplete glucose stores. The infant may react to exposure to cold by increasing the respiratory rate and may become cyanotic. Ways to stabilize the newborn’s body temperature include placing the infant directly on the mother’s abdomen and covering with a warm blanket (skin-

Assessment and Care of the Newborn

577

signs of

POTENTIAL COMPLICATIONS

Abnormal Newborn Breathing

Bradypnea: respirations ( 25/min)

Ta chypnea: respirations ( 60/min)

Abnormal breath sounds: crackles, rhonchi, wheezes, expiratory grunt

Respiratory distress: nasal flaring, retractions, chin tug, labored breathing

to-skin contact); drying and wrapping the newborn in warmed blankets immediately after birth; keeping the head well covered; and keeping the ambient temperature of the nursery at 23.8° to 26.1° C (AAP & ACOG, 2002). If the infant does not remain with the mother during the first 1 to 2 hours after birth, the nurse places the thoroughly dried infant under a radiant warmer until the body tem- perature stabilizes. The infant’s skin temperature is used as the point of control in a warmer with a servocontrolled mechanism. The control panel usually is maintained between 36° and 37°C. This setting should maintain the healthy new- born’s skin temperature at approximately 36.5° to 37°C. A thermistor probe (automatic sensor) is taped to the right up- per quadrant of the abdomen immediately below the right intercostal margin (never over a bone). A reflector adhesive patch may be used over the probe to provide adequate warm- ing. This will ensure detection of minor changes resulting from external environmental factors or neonatal factors (pe- ripheral vasoconstriction, vasodilation, or increased me- tabolism) before a dramatic change in core body tempera- ture develops. The servocontroller adjusts the warmer temperature to maintain the infant’s skin temperature within the present range. The sensor must be checked periodically to make sure it is securely attached to the infant’s skin. The axillary temperature of the newborn is checked every hour (or more often as needed) until the newborn’s temperature stabilizes. The time to stabilize and maintain body temper- ature varies; each newborn should therefore be allowed to achieve thermal regulation as necessary, and care should be individualized. During all procedures, heat loss must be avoided or min- imized for the newborn; therefore examinations and activ- ities are performed with the newborn under a heat panel. The initial bath is postponed until the newborn’s skin tempera- ture is stable and can adjust to heat loss from a bath. The exact and optimal timing of the bath for each newborn re- mains unknown. Even a normal term infant in good health can become hypothermic. Birth in a car on the way to the hospital, a cold birthing room, or inadequate drying and wrapping imme- diately after birth may cause the newborn’s temperature to fall below the normal range (hypothermia). Warming the hypothermic infant is accomplished with care. Rapid warm- ing may cause apneic spells and acidosis in an infant. The

578

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THE NEWBORN

warming process is monitored to progress slowly over a pe- riod of 2 to 4 hours.

Therapeutic interventions It is the nurse’s responsibility to perform certain inter- ventions immediately after birth to provide for the safety of the newborn. Eye prophylaxis. The instillation of a prophylactic agent in the eyes of all neonates is mandatory in the United States as a precaution against ophthalmia neonatorum (Fig. 19-4). This is an inflammation of the eyes resulting from gonorrheal or chlamydial infection contracted by the new- born during passage through the mother’s birth canal. The agent used for prophylaxis varies according to hospital pro- tocols, but the usual agent is erythromycin, tetracycline, or silver nitrate. In some institutions, eye prophylaxis is delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding are facilitated. The Centers for Disease Control and Prevention specifies that it should be given as soon as possible after birth; if instillation is delayed, there should be a monitoring process in place to ensure that all newborns are treated (Workowski & Levine, 2002) (Medication Guide). In the United States, if parents object to eye prophylaxis, they may be asked to sign an in- formed refusal form, and their refusal will be noted in the infant’s record. Topical antibiotics such as tetracycline and erythromycin, silver nitrate, and a 2.5% povidone-iodine solution (currently unavailable in commercial form in the United States) have not proved to be effective in the treatment of chlamydial conjunctivitis.

be effective in the treatment of chlamydial conjunctivitis. F ig. 19-4 Instillation of medication into eye

Fig. 19-4 Instillation of medication into eye of newborn. Thumb and forefinger are used to open the eye; medication is placed in the lower conjunctiva from the inner to the outer canthus. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

Medication Guide

Eye Prophylaxis: Erythromycin Ophthalmic Ointment, 0.5%, and Tetracycline Ophthalmic Ointment, 1%

ACTION

These antibiotic ointments are both bacteriostatic and bactericidal.They provide prophylaxis against Neisse- ria gonorrhoeae and Chlamydia trachomatis.

INDICATION

These medications are applied to prevent ophthalmia neonatorum in newborns of mothers who are infected with gonorrhea, conjunctivitis, and chlamydia.

NEONATAL DOSAGE

Apply a 1- to 2-cm ribbon of ointment to the lower con- junctival sac of each eye; also may be used in drop form.

ADVERSE REACTIONS

May cause chemical conjunctivitis that lasts 24 to 48 hours; vision may be blurred temporarily.

NURSING CONSIDERATIONS

Administer within 1 to 2 hr of birth. Wear gloves. Cleanse eyes if necessary before administration. Open eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. Squeeze the tube and spread the ointment from the in- ner canthus of the eye to the outer canthus. Do not touch the tube to the eye. After 1 min, excess ointment may be wiped off. Observe eyes for irritation. Explain treatment to parents.

Eye prophylaxis for ophthalmia neonatorum is required by law in all states of the United States.

A 14-day course of oral erythromycin or an oral sulfon- amide may be given for chlamydial conjunctivitis (AAP & ACOG, 2002) (see Medication Guide). Vitamin K administration. For the first few days after birth the newborn is at risk for prolonged clotting and bleeding because of vitamin K deficiency. Vitamin K is poorly transferred across the placenta or through breast milk, and the infant’s intestines are not yet colonized by mi- croflora that synthesize vitamin K. Administering vitamin K intramuscularly is routine in the newborn period. A sin- gle parenteral dose of 0.5 to 1 mg of vitamin K is given soon after birth to prevent hemorrhagic disorders (Kliegman, 2002; Miller & Newman, 2005). By day 8, term newborns are able to produce their own vitamin K (Medication Guide).

NURSE ALERT

Vitamin K is never administered by the in-

travenous route for prevention of hemorrhagic disease of the newborn except in some cases of a preterm in- fant who has no muscle mass. In such cases, the med- ication should be diluted and given over 10 to 15 min- utes, with the infant being closely monitored with a cardiorespiratory monitor. Rapid bolus administration of vitamin K may cause cardiac arrest.

Medication Guide

C HAPTER

19

Vitamin K: Phytonadione (AquaMEPHYTON, Konakion)

ACTION

This intervention provides vitamin K because the new- born does not have the intestinal flora to produce this vitamin in the first week after birth. It also promotes formation of clotting factors (II, VII, IX, X) in the liver.

INDICATION

Vitamin K is used for prevention and treatment of hem- orrhagic disease in the newborn.

NEONATAL DOSAGE

Administer a 0.5- to 1-mg (0.25- to 0.5-ml) dose intra- muscularly within 2 hr of birth; may be repeated if new- born shows bleeding tendencies.

ADVERSE REACTIONS

Edema, erythema, and pain at injection site may occur rarely; hemolysis, jaundice, and hyperbilirubinemia have been reported, particularly in preterm infants.

NURSING CONSIDERATIONS

Wear gloves. Administer in the middle third of the vas- tus lateralis muscle by using a 25-gauge, 5 8-inch nee- dle. Inject into skin that has been cleaned, or allow al- cohol to dry on puncture site for 1 min to remove organisms and prevent infection. Stabilize leg firmly, and grasp muscle between the thumb and fingers. In- sert the needle at a 90-degree angle; release muscle; aspirate, and inject medication slowly if there is no blood return. Massage the site with a dry gauze square after removing needle to increase absorption. Observe for signs of bleeding from the site.

Umbilical cord care. The cord is clamped imme- diately after birth. The goal of cord care is to prevent or de- crease the risk of hemorrhage or infection. The umbilical cord stump is an excellent medium for bacterial growth and can easily become infected (Miller & Newman, 2005).

If bleeding from the blood vessels of the

cord is noted, the nurse checks the clamp (or tie) and ap- plies a second clamp next to the first one. If bleeding is not stopped immediately, the nurse calls for assis- tance.

Hospital protocol directs the time and technique for rou- tine cord care. Many hospitals have subscribed to the prac- tice of “dry care” consisting of cleaning the periumbilical area with soap and water and wiping it dry. Others apply an an- tiseptic solution such as Triple Dye or alcohol to the cord (Janssen, Selwood, Dobson, Peacock, & Thiessen, 2003). Cur- rent recommendations for cord care by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) include cleaning the cord with sterile water or a neutral pH cleanser. Subsequent care entails cleansing the cord with water (AWHONN, 2001). The stump and base of

NURSE ALERT

Assessment and Care of the Newborn

579

base of NURSE ALERT Assessment and Care of the Newborn 579 F ig. 19-5 dries (about

Fig. 19-5

dries (about 24 hours). (Courtesy Marjorie Pyle, RNC, Lifecir- cle, Costa Mesa, CA.)

With special scissors, remove clamp after cord

the cord should be assessed for edema, redness, and puru- lent drainage with each diaper change. The cord clamp is re- moved after 24 hours when the cord is dry (Fig. 19-5). Cord separation time is influenced by a number of factors, in- cluding type of cord care, type of birth, and other perina- tal events. The average cord separation time is 10 to 14 days.

Promoting parent-infant interaction Today’s childbirth practices strive to promote the family as the focus of care. Parents generally desire to share in the birth process and have early contact with their infants. Early contact between mother and newborn can be important in developing future relationships. It also has a positive effect on the duration of breastfeeding. The physiologic benefits of early mother-infant contact include increased oxytocin and prolactin levels in the mother and activation of sucking reflexes in the infant. The infant can be put to breast soon after birth. The process of developing active immunity be- gins as the infant ingests flora from the mother’s colostrum.

Evaluation Evaluation of the effectiveness of immediate care of the new- born is based on the previously stated outcomes.

CARE MANAGEMENT: FROM 2 HOURS AFTER BIRTH UNTIL DISCHARGE

The infant’s admission to the nursery may be delayed, or it may never actually occur. Depending on the routine of the hospital, the infant frequently remains in the labor area and is then transferred to either the nursery or the postpartum unit with the mother. Many hospitals have adopted varia- tions of single-room maternity care (SRMC) or mother-baby care in which one nurse provides care for the mother and newborn. SRMC allows the infant to remain with the parents after the birth. Many of the procedures, such as

mother and newborn. SRMC allows the infant to remain with the parents after the birth. Many
580 U NIT S I X THE NEWBORN EVIDENCE-BASED PRACTICE Optimum Duration of Exclusive Breastfeeding:
580 U NIT
S I X
THE NEWBORN
EVIDENCE-BASED PRACTICE
Optimum Duration of Exclusive Breastfeeding: Systematic World Health
Organization Review
BACKGROUND
Statistical Analyses
• Breastfeeding provides many documented health bene-
fits and can be lifesaving in developing countries. Breast-
feeding has a protective effect against gastrointestinal and
respiratory infection, sudden infant death syndrome
(SIDS), atopic disease, obesity, diabetes, Crohn’s disease,
and lymphoma. Breastfeeding may accelerate neu-
rocognitive development and achievement. Maternal
health benefits include possible protection against
breast cancer, ovarian cancer, and osteoporosis.
• Statistical analyses were possible in only the two con-
trolled trials.The observational studies were too hetero-
geneous and limited by design to pool data.
FINDINGS
• An observation of “growth faltering” at about 3 months
of age in developing countries has led to questions about
the nutritional and energy content of breast milk after
3 or 4 months, the nutritional quality of supplemental
foods introduced at about 3 to 4 months, and the risk of
infection-caused energy deficit in infants. A debate about
the “weanling’s dilemma” stemmed from questions
about inadequate breast milk nutrition versus nutrition-
ally inadequate or contaminated weaning foods. WHO re-
• The authors found no significant difference in weight,
length, or atopic disease in the two groups. Exclusively
breastfed infants had significantly decreased gastroin-
testinal infections.There was a marginally significant de-
crease in the iron stores of exclusively breastfed infants
in developing countries at 6 months, unless they were re-
ceiving an iron supplement. Maternal weight loss was ac-
celerated in exclusive breastfeeding, and lactational
amenorrhea was prolonged.
LIMITATIONS
quested this review of available evidence regarding the
optimum duration of breastfeeding.
OBJECTIVES
• All agreed that exclusive breastfeeding was best for 3 to
4 months. The reviewers compared health, growth, and
• Observational studies are subject to bias. Confounding
by indication refers to statistical errors that occur because
the reason for the treatment (i.e., food supplementation
given to a growth-faltering breastfed infant) affects the
outcome. Bias can also occur because of reverse causal-
ity. For example, an infant with an infection becomes
anorectic and reduces milk intake to the point of loss of
milk production. The infection might be blamed on the
weaning, instead of the reverse.
development outcomes for those who continued exclu-
sive breastfeeding until 6 months, versus those who grad-
ually added supplemental liquid or food to breastfeeding.
The participants could all be healthy, singleton, term in-
CONCLUSIONS
fants (low birth weight accepted, as long as gestationally
full term). Infant outcome measures could include
weight, length, head circumference, infections, morbid-
ity, mortality, micronutrient status, neuromotor and cog-
nitive developmental milestones, atopic disease, type
1 diabetes, blood pressure, adult chronic illnesses, and
inflammatory and autoimmune diseases. Maternal out-
come measures include postpartum weight loss, lacta-
tional amenorrhea, breast and ovarian cancer, and os-
teoporosis.
• The researchers found no evidence of a “weanling’s
dilemma,” and no benefits from adding supplemental
food between 4 and 6 months. The iron deficit of exclu-
sively breastfed babies in developing countries can be
corrected with infant drops and does not warrant the loss
of protection against gastrointestinal and respiratory in-
fections that exclusive breastfeeding confers. Maternal
lactational amenorrhea provides contraceptive benefit for
child spacing. Rapid postpartum weight loss may not ben-
efit women with marginal nutritional status. The policy
statements of WHO and the World Health Assembly were
modified to reflect the recommendation for exclusive
breastfeeding for the first 6 months of life.
METHODS
Search Strategy
IMPLICATIONS FOR PRACTICE
• Search of world literature included Cochrane, MEDLINE,
EMBASE, CINAHL, HealthSTAR, EBM Reviews—Best Ev-
idence, SocioFile, CAB Abstracts, EMBASE—Psychology,
EconLit, Index Medicus for the WHO Eastern Mediter-
ranean, African Index Medicus, and LILACS Latin Amer-
ican and Caribbean literature. Search keywords included
exclusive breastfeeding and growth.
• Exclusive breastfeeding should be recommended. Iron
supplements for breastfeeding infants are beneficial.The
contraceptive benefits of lactational amenorrhea are im-
portant.
IMPLICATIONS FOR FURTHER RESEARCH
• Twenty studies were reviewed, nine from developing
countries (including the Philippines, Peru, Chile, Honduras,
Bangladesh, Belarus, East India, and Senegal) and eleven
from developed countries (the United States, Sweden,
Finland, Australia, and Italy).The studies were published
from 1980 to 2000. Two were controlled trials from
Honduras, and the rest were observational studies.
• Public health policy demands information about breast-
feeding beyond the observational stage. Large, random-
ized trials are needed, especially in developing countries,
to confirm infection morbidity and infant nutritional sta-
tus in exclusively breastfed infants of 6 months’ duration
or longer. Costs are not addressed in these studies. More
information on long-term outcomes is needed.

Reference: Kramer, M., & Kakuma, R. (2001). Optimal duration of exclusive breastfeeding (Cochrane Review). In The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.

C HAPTER

19

assessment of weight and measurement (i.e., circumference of head and chest, length), instillation of eye medications, intramuscular administration of vitamin K, and physical as- sessment, may be carried out in the labor and birth unit. Nurses who work in an SRMC unit; labor, delivery, and re- covery (LDR) room; or labor, delivery, recovery, and post- partum (LDRP) room must be knowledgeable and compe- tent in intrapartal, neonatal, and postpartum nursing care. If an infant is transferred to the nursery, the infant’s iden- tification is verified by the nurse receiving the infant, who places the baby in a warm environment and begins the ad- mission process. Regardless of the physical organization for care, many hospitals have a small holding nursery, which is available for procedures or on the request of the mother who wishes her infant to be placed there. This arrangement promotes parent- infant bonding while still allowing the new parents some time to be alone.

Assessment Gestational age assessment

Assessment of gestational age is an important criterion be- cause perinatal morbidity and mortality rates are related to gestation age and birth weight. The simplified Assessment of Gestational Age (Ballard, Novak, & Driver, 1979) is com- monly used to assess gestational age of infants between

35 and 42 weeks. It assesses six external physical and six neu-

romuscular signs. Each sign has a number score, and the cu- mulative score correlates with a maturity rating of 26 to

44 weeks of gestation. The score is accurate to plus or mi-

nus 2 weeks and is accurate for infants of all races. The New Ballard Score, a revision of the original scale, can be used with newborns as young as 20 weeks of gesta- tion. The tool has the same physical and neuromuscular sec- tions but includes 1 to 2 scores that reflect signs of extremely premature infants, such as fused eyelids; imper- ceptible breast tissue; sticky, friable, transparent skin; no lanugo; and square-window (flexion of wrist) angle greater than 90 degrees (see Fig. 19-1, A). The examination of in- fants with a gestational age of 26 weeks or less should be per- formed at a postnatal age of less than 12 hours. For infants with a gestational age of at least 26 weeks, the examination can be performed up to 96 hours after birth. To ensure ac- curacy, it is recommended that the initial examination be performed within the first 48 hours of life. Neuromuscular adjustments after birth in extremely immature neonates re- quire that a follow-up examination be performed to further validate neuromuscular criteria. The scale overestimates ges- tational age by 2 to 4 days in infants younger than 37 weeks of gestation, especially at gestational ages of 32 to 37 weeks (Ballard et al., 1991).

Classification of newborns by gestational age and birth weight Classification of infants at birth by both birth weight and gestational age provides a more satisfactory method

Assessment and Care of the Newborn

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for predicting mortality risks and providing guidelines for management of the neonate than estimating gestational age or birth weight alone. The infant’s birth weight, length, and head circumference are plotted on standardized graphs that identify normal values for gestational age. A normal

range of birth weights exists for each gestational week (see Fig. 19-1, B), but the birth weights of preterm, term, post- term, or postmature newborns also may be outside these normal ranges. Birth weights are classified in the follow- ing ways:

Large for gestational age (LGA)—Weight is above the 90th percentile (or two or more standard deviations above the norm) at any week.

Appropriate for gestational age (AGA)—Weight falls be- tween the 10th and 90th percentile for infant’s age.

Small for gestational age (SGA)—Weight is below the 10th percentile (or two or more standard deviations below the norm) at any week.

Low birth weight (LBW)—Weight of 2500 g or less at birth. These newborns have had either less than the ex- pected rate of intrauterine growth or a shortened ges- tation period. Preterm birth and LBW commonly oc- cur together (e.g., less than 32 weeks of gestation and birth weight of less than 1200 g).

Very low birth weight (VLBW)—Weight of 1500 g or less at birth.

Intrauterine growth restriction (IUGR)—Term applied to the fetus whose rate of growth does not meet expected norms. Newborns are classified according to their gestational ages in the following ways:

Preterm or premature—Born before completion of

37 weeks of gestation, regardless of birth weight

Term—Born between the beginning of week 38 and the end of week 42 of gestation

Postterm (postdate)—Born after completion of week

42 of gestation

Postmature—Born after completion of week 42 of ges- tation and showing the effects of progressive placen- tal insufficiency Maternal effects on gestational age assess- ment and birth weight. Some maternal conditions can affect the results of the gestational assessment. For in- stance, any infant who has had oxygen deprivation during labor will show poor muscle tone. Infants in respiratory dis- tress tend to be flaccid and assume a “frog-leg” posture. Even though an infant may look large, such as the infant of a di- abetic mother, it may respond more like a premature infant. The infant of a mother who has been receiving magnesium sulfate will tend to be somewhat lethargic.

Physical assessment A complete physical examination is performed within 24 hours after birth. The parents’ presence during this ex- amination encourages discussion of parental concerns and actively involves the parents in the health care of their infant

Evolve/CD: Case Study—Normal Newborn

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U NIT

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from birth. It also affords the nurse an opportunity to ob- serve parental interactions with the infant. The area used for the examination should be well lighted, warm, and free from drafts. The infant is undressed as needed and placed on a firm, warmed, flat surface or under a radi- ant warmer. The physical assessment should begin with a re- view of the maternal history and prenatal and intrapartal records. This provides a background for the recognition of any potential problems. The assessment includes general appearance, behavior, vi- tal signs measurement, and parent-infant interactions. The assessment should progress systematically from head to toe, with assessment and evaluation of each system (i.e., car- diovascular, respiratory, and so on). Descriptions of any vari- ations from normal findings and all abnormal findings are included. The findings provide a database for implementing the nursing process with newborns and providing anticipa- tory guidance for the parents. (Table 19-2 summarizes the newborn assessment.) Ongoing assessments of the newborn are made throughout the hospital stay, and an evaluation is performed before discharge. Nursing considerations in assessment. The neonate’s maturity level can be gauged by assessment of gen- eral appearance. Features to assess in the general survey in- clude skin color, posture, state of alertness, cry, head size, lanugo, vernix caseosa, breast tissue, and sole creases. The normal resting posture of the neonate is one of general flex- ion. The neck is short, and the abdomen is prominent. The temperature, heart rate, and respiratory rate are always obtained. Blood pressure (BP) is not routinely assessed un- less cardiac problems are suspected. An irregular, very slow, or very fast heart rate may indicate a need for BP measure- ments. The axillary temperature is a safe, accurate substitute for the rectal temperature. Electronic thermometers have ex- pedited this task and provide a reading within 1 minute. Tak- ing an infant’s temperature may cause the infant to cry and struggle against the placement of the thermometer in the ax- illa. Tympanic thermometers may be used after the new- born’s ear canals are free of vernix and fluid. Before taking the temperature, the examiner may want to determine the apical heart rate and respiratory rate while the infant is quiet and at rest. The normal axillary temperature averages 37° C with a range from 36.5° C to 37.2° C. The respiratory rate varies with the state of alertness af- ter birth. Respirations are abdominal and can easily be counted by observing or lightly feeling the rise and fall of the abdomen. Neonatal respirations are shallow and irreg- ular. It is important to count the respirations for a full minute to obtain an accurate count because of normal short peri- ods of apnea. The examiner also should observe for sym- metry of chest movements (see Table 19-2 for normal res- piratory rates). Apical pulse rates should be obtained for all infants. Aus- cultation should be for a full minute, preferably when the infant is asleep. The infant may need to be held and com-

forted during assessment. Auscultation of the heart sounds

is difficult because of the rapid rate and effective transmis-

sion of respiratory sounds. However, the first (S 1 ) and sec- ond (S 2 ) sounds should be clear and well defined; the sec- ond sound is somewhat higher in pitch and sharper than the first. Murmurs are often heard in the newborn, especially

over the base of the heart or at the left sternal border in the third or fourth interspace. These are usually functional mur- murs resulting from incomplete closure of fetal shunts. Any murmur or other unusual sounds should be recorded and reported. See Table 19-2 for normal heart rates.

If BP is measured, a Doppler (electronic) monitor facili-

tates this procedure. It is important to use the correct size BP cuff. Neonatal BP usually is highest immediately after birth and decreases to a minimum by 3 hours after birth. It then begins to increase steadily and reaches a plateau be- tween 4 and 6 days after birth. This measurement is usually equal to that of the immediate postbirth BP. BP may be measured in both arms and legs to detect any discrepancy between the two sides or between the upper and lower body.

A discrepancy of 10 mm Hg or more between the arms and

legs may signal a cardiac defect such as coarctation of the aorta. Molding may give the neonate’s head an asymmetric ap-

pearance (see Fig. 18-9). Parents should be reassured that this will go away and that nothing need be done to the head. Fa- cial asymmetry may occur from fetal positioning in utero; asymmetry usually disappears spontaneously over time. The hard and soft palates are assessed with the gloved little fin- ger of the examiner. At the same time the suck reflex can be assessed.

A gross assessment of hearing can be done by watching

A gross assessment of hearing can be done by watching the neonate’s response to voices or

the neonate’s response to voices or other sounds; a loud noise should elicit a startle reflex. Formal hearing screening of all infants is conducted in the newborn nursery. The nose is examined for size, shape, mucous membrane integrity, and discharge. The nose should be midline on the face. The nares are checked for patency by occluding one nostril at a time and observing for respirations. When palpating the clavicles, the examiner moves the fin- gers slowly over the anterior clavicular surface. If a mass or lump is detected, the examiner tries to move the neonate’s arm gently while palpating with the other hand. A crepitant, grating sensation and uneven movement of two juxtaposed bone fragments indicate a fracture. If a fractured clavicle is present, the infant will usually have limited movement of the arm on the affected side. Breast tissue is assessed through observation and palpa- tion. To measure breast tissue, palpate the nipple gently with one finger or place the second and third fingers on either side of the nipple. The amount of breast tissue is measured be- tween the two fingers. Breast tissue and areola size increase with gestational age. Movement of the arms should be assessed. Trauma to the brachial plexus during a difficult birth may result in brachial

palsy. The most common type, Duchenne-Erb paralysis, in-

C HAPTER

19

volves the fifth and sixth cervical nerve roots (see Fig. 27-2). The affected arm is held in a position of tight adduction and internal rotation at the shoulder. The grasp reflex on the af- fected side may be intact; however, the Moro reflex is absent on that side. With treatment, most neonates have complete recovery. Surgery may be necessary in some instances. A neurologic assessment of the newborn’s reflexes (see Table 18-3) provides useful information about the infant’s nervous system and state of neurologic maturation. The as- sessment must be carried out as early as possible because ab- normal signs present in the early neonatal period may dis- appear. They may reappear months or years later as abnormal functions.

Common problems in the newborn Physical injuries. Birth trauma includes any phys- ical injury sustained by a newborn during labor and birth. Although most injuries are minor and resolve during the neonatal period without treatment, some types of trauma re- quire intervention. A few are serious enough to be fatal. Factors that may predispose the neonate to birth trauma include prolonged or precipitous labor, preterm labor, fetal macrosomia, cephalopelvic disproportion, abnormal pre- sentation, and congenital anomalies. Injury can be the re- sult of obstetric birth techniques such as forceps-assisted birth, vacuum extraction, version and extraction, and ce- sarean birth (Efird & Hernandez, 2005). Soft tissue injuries. Cephalhematoma is the most common type of cranial injury in newborns and can be as- sociated with an underlying skull fracture. Caput succeda-

sociated with an underlying skull fracture. Caput succeda- F ig. 19-6 Marked bruising on the entire

Fig. 19-6 Marked bruising on the entire face of an infant born vaginally after face presentation. Less severe ecchy- moses were present on the extremities. Phototherapy was re- quired for treatment of jaundice resulting from the breakdown of accumulated blood. (From O’Doherty, N. [1986]. Neona- tology: Micro atlas of the newborn. Nutley, NJ: Hoffman- LaRoche.)

Assessment and Care of the Newborn

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Hoffman- LaRoche.) Assessment and Care of the Newborn 583 Fig. 19-7 Swelling of the genitals and

Fig. 19-7 Swelling of the genitals and bruising of the but- tocks after a breech birth. (From O’Doherty, N. [1986]. Neona- tology: Micro atlas of the newborn. Nutley, NJ: Hoffman- LaRoche.)

neum is diffuse swelling of the soft tissues of the scalp and is a result of pressure of the uterus or vaginal wall on the fe- tal head (Efird & Hernandez, 2005). Caput succedaneum and cephalhematoma are described in Chapter 18 (see Fig. 18-5). Subconjunctival and retinal hemorrhages result from rup- ture of capillaries caused by increased pressure during birth (see Chapter 18). These hemorrhages usually clear within 5 days after birth and present no further problems. Parents need explanation and reassurance that these injuries will re- solve without sequelae. Erythema, ecchymoses, petechiae, abrasions, lacerations, or edema of buttocks and extremities may be present. Lo- calized discoloration may appear over presenting parts and may result from the application of forceps or the vacuum extractor. Ecchymoses and edema may appear anywhere on the body. Bruises over the face may be the result of face presenta- tion (Fig. 19-6). In a breech presentation, bruising and swelling may be seen over the buttocks or genitalia (Fig. 19-7). The skin over the entire head may be ecchymotic and covered with petechiae caused by a tight nuchal cord. Pe- techiae (pinpoint hemorrhagic areas) acquired during birth may extend over the upper trunk and face. These lesions are benign if they disappear within 2 or 3 days of birth and no new lesions appear. Ecchymoses and petechiae may be signs of a more serious disorder, such as thrombocytopenic purpura.

NURSE ALERT

To differentiate hemorrhagic areas from

skin rashes and discolorations, try to blanch the skin with two fingers. Petechiae and ecchymoses do not blanch because extravasated blood remains within the tissues, whereas skin rashes and discolorations do.

CD: Critical Thinking Exercise—Jaundice

CD: Critical Thinking Exercise—Jaundice 5 8 4 U NIT S I X THE NEWBORN T rauma

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Trauma resulting from dystocia occurs to the presenting fetal part. Forceps injury and bruising from the vacuum cup

occur at the site where the instruments were applied. In a for- ceps injury, commonly a linear mark appears across both sides of the face in the shape of the forceps blades. The af- fected areas are kept clean to minimize the risk of infection. With the increased use of the vacuum extractor and the use

of

padded forceps blades, the incidence of these lesions may

be

significantly reduced (Mangurten, 2002).

Accidental lacerations may be inflicted with a scalpel dur- ing a cesarean birth. These cuts may occur on any part of the body but are most often found on the face, scalp, buttocks, and thighs. Usually they are superficial and only need to be

kept clean. Liquid skin adhesive or butterfly adhesive strips can hold together the edges of more serious lacerations. Rarely are sutures needed. Skeletal injuries. Fracture of the clavicle (collarbone) is the most common birth injury. This injury is often asso- ciated with macrosomia and is a result of compression of the shoulder or manipulation of the affected arm during birth.

A fractured clavicle usually heals without treatment, al-

though the arm and shoulder may be immobilized for com- fort (Efird & Hernandez, 2005). Fractures of the humerus and femur may occur during a difficult birth, but such fractures in newborns generally heal rapidly. Immobilization is accomplished with slings, splints, swaddling, and other devices. The infant’s immature, flexible skull can withstand a great deal of molding before fracture results. Fractures may occur during difficult births and result from the head pressing on the bony pelvis or from the injudicious application of for- ceps (Fig. 19-8). The location of a skull fracture determines

(Fig. 19-8). The location of a skull fracture determines F ig. 19-8 Depressed skull fracture in

Fig. 19-8 Depressed skull fracture in a term male after rapid (1-hour) labor. The infant was delivered by occiput- anterior position after rotation from occiput-posterior position. (From Mangurten, H. (2002), Birth injuries. In A. Fanaroff & R. Martin, Neonatal-perinatal medicine: Diseases of the fetus and infant [7th ed.]. St. Louis: Mosby.)

whether it is insignificant or fatal. Spontaneous or nonsur- gical elevation of the indentation using a hand breast pump or vacuum extractor has been reported. Nerve injuries may result in temporary or permanent paralysis. Brachial plexus injuries can affect movement of the shoulder, arm, wrist, or hand. Phrenic nerve palsy can occur because of hyperextension of the neck during difficult birth and can cause respiratory distress. Facial palsy affects one side of the face and is usually self-limiting (Efird &am