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C h a p t e r
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 gestational 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 newborn 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 circumcision, the postoperative care of the circumcised 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 physiologic 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 exposure to cold
ophthalmia neonatorum Infection in the neonates

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 bilirubin levels by oxidation of bilirubin into watersoluble 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/
NCLEX Review Questions
Case StudyNormal Newborn
WebLinks
or on the interactive companion CD

NCLEX Review Questions
Case StudyNormal Newborn
Critical Thinking ExerciseCircumcision
Critical Thinking ExerciseJaundice
Plan of CareNormal Newborn
SkillChanging a Diaper
SkillInfant Bathing
SkillPain Assessment
VideoAssessment of the Newborn
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THE NEWBORN
BOX 19-1
he numerous biologic changes the neonate makes during the transition to extrauterine life are discussed in the preceding
chapter. The first 24 hours are critical because respiratory distress and circulatory failure can occur
rapidly and with little warning. Although most infants make
the necessary biopsychosocial adjustment to extrauterine existence without undue difficulty, their well-being depends on
the care they receive from others. This chapter describes assessment and care of the infant immediately after birth until discharge, as well as important parent education related
to ongoing infant care. A discussion of pain in the neonate
and its management is included.
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:
CARE MANAGEMENT:
FROM BIRTH THROUGH
THE FIRST 2 HOURS
Care begins immediately after birth and focuses on assessing and stabilizing the newborns condition. The nurse has
primary responsibility for the infant during this period, because the physician or nurse-midwife is involved with delivery of the placenta and caring for the mother. The nurse
must be alert for any signs of distress and must initiate appropriate 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 newborns 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 handling the newborn until blood and amniotic fluid are removed by bathing.
Assessment and
Nursing Diagnoses
The initial assessment of the neonate is done at birth by using the Apgar score (Table 19-1) and a brief physical examination (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).
Apgar score
The Apgar score permits a rapid assessment of the need
for resuscitation based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation 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;
TABLE 19-1
Apgar Score
SCORE
SIGN
Heart rate
Respiratory rate
Muscle tone
Reflex irritability
Color
Absent
Absent
Flaccid
No response
Blue, pale
Slow (100)
Slow, weak cry
Some flexion of extremities
Grimace
Body pink, extremities blue
100
Good cry
Well flexed
Cry
Completely pink
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Assessment and Care of the Newborn
561
Fig. 19-1 Estimation of gestational age. A, New Ballard Scale for newborn maturity rating. Expanded 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 extremely 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 newborns transition
to extrauterine environment (Box 19-2). Should resuscitation 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; assess nasal patency by covering one nostril at a time while
observing respirations; skin: peeling, or lack of subcutaneous fat (dysmaturity or postterm); note meconium
staining of cord, skin, fingernails, or amniotic fluid (staining may indicate fetal release of meconium, often related
to hypoxia; offensive odor may indicate intrauterine infection); 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
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THE NEWBORN
CLASSIFICATION OF NEWBORNS
BASED ON MATURITY AND INTRAUTERINE GROWTH
Symbols: X - 1st Examination O - 2nd Examination
CM
53
52
51
50
49
48
47
46
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
CM
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
0
90%
LENGTH
cm
50%
10%
90%
HEAD CIRCUMcm
FERENCE
50%
10%
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
WEEK OF GESTATION
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
1st Examination
(X)
WEEK OF GESTATION
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
GM
4200
4000
3800
3600
3400
3200
3000
2800
2600
2400
2200
2000
1800
1600
1400
1200
1000
800
600
400
0
WEIGHT
2nd Examination
(O)
LARGE
FOR
GESTATIONAL
AGE
(LGA)
gm
90%
50%
APPROPRIATE
FOR
GESTATIONAL
AGE
(AGA)
10%
SMALL
FOR
GESTATIONAL
AGE
(SGA)
Age at Examination
Signature
of
Examiner
PRETERM
TERM
hrs
hrs
M.D.
M.D.
POSTTERM
Fig. 19-1, contd Estimation of gestational age. B, Newborn classification based on maturity and intrauterine growth. (Modified from Lubchenco, L., Hansman, C., & Boyd, E. [1966]. Intrauterine 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.)
other adventitious sounds; note equality of breath

sounds by auscultation.
3. Abdomen: Observe characteristics of abdomen
(rounded, flat, concave) and absence of anomalies; auscultate 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 immediately after birth verifies that respirations have been
Text continued on p. 575.
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TABLE 19-2
Physical Assessment of Newborn

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
Vertex: arms, legs in moderate flexion; fists clenched

Normal spontaneous movement bilaterally asynchronous but equal extension
in all extremities
Frank breech: legs straighter
and stiff
Hypotonia
Visible pulsations in left

midclavicular line, fifth intercostal space
Apical pulse, fourth intercostal space 100-160
beats/min
80-100 beats/min (sleeping)
to 180 beats/min (crying)
Quality: first sound (closure
of mitral and tricuspid
valves) and second sound
(closure of aortic and pulmonic valves) sharp and
clear
Possible murmur
Tachycardia: persistent,
180 beats/min
Bradycardia: persistent,
80 beats/min
Murmurs
Arrhythmias: irregular rate
Sounds distant,
poor quality, extra
Heart on right side of chest
Respiratory distress
syndrome (RDS)
Congenital heart block, maternal lupus
Possibly functional
Peripheral pulses:
femoral, brachial,
popliteal, posterior tibial
Peripheral pulses equal and

strong
Femoral pulses equal and
strong
Weak or absent peripheral
Decreased cardiac output,

thrombus
Hip dysplasia, coarctation of
aorta if weak on left and
strong on right, thrombophlebitis
Temperature
Axillary: 36.5 C to 37.2 C

Temperature stabilized by
8-10 hr of age
Subnormal
Inspect newborn before disturbing

Refer to maternal chart for
fetal presentation, position, and type of birth
(vaginal, surgical), because newborn readily
assumes prenatal
position
Hypertonia
Opisthotonos
Limitation of motion in any
of extremities (see p. 573)
Prematurity or hypoxia in
utero, maternal medications
Drug dependence, central
nervous system (CNS)
disorder
CNS disturbance
VITAL SIGNS
Heart rate and pulses:

Inspection
Palpation
Auscultation
Weak or absent femoral

pulses; unequal
Increased
Temperature not stabilized

by 6-8 hr after birth
Check respiratory rate and
effort when infant is at
rest
Count respirations for full
minute
30-60 breaths/min
Shallow and irregular in
rate, rhythm, and depth
when infant is awake
Crackles may be heard after
birth
Apneic episodes: 15 sec

Bradypnea: 25/min
Pneumomediastinum
Dextrocardia, often accompanied by reversal of intestines
Prematurity, infection, low

environmental temperature, inadequate clothing,
dehydration
Infection, high environmental temperature, excessive clothing, proximity to
heating unit or in direct
sunshine, drug addiction,
diarrhea and dehydration
If mother received magnesium sulfate, maternal
analgesics
Preterm infant: periodic
breathing, rapid warming or cooling of infant
Maternal narcosis from
analgesics or anesthetics,
birth trauma
Continued
CD: VideoAssessment of the Newborn
POSTURE
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THE NEWBORN
TABLE 19-2
Physical Assessment of Newborncontd

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
VITAL SIGNScontd
Breath sounds loud, clear,

near
Measure blood pressure

(BP) using oscillometric
monitor BP cuff; palpate
brachial, popliteal, or posterior tibial pulse (depending on measurement
site)
Check electronic monitor
BP cuff: BP cuff width affects readings, use cuff
2.5 cm wide and palpate
radial pulse
80-90s/40s-50s
Tachypnea: 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 diaphragmatic 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
WEIGHT*
Weigh at same time each

day
2500-4000 g
Acceptable weight loss:
10%
Second baby weighs more
than first
Birth weight regained within
first 2 weeks
Weight 2500 g
Weight 4000 g
Weight loss 10% to 15%
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.
Prematurity, small for

gestational age, rubella
syndrome
Large for gestational age,
maternal diabetes,
hereditynormal for
these parents
Dehydration
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TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
45-55 cm
45 cm or 55 cm
ETIOLOGY
LENGTH
Length from top of head to

heel
Chromosomal abnormality,
hereditynormal for
these parents
Length, crown to rump. To determine total length, include

length of legs. If measurements are taken before the infants
initial bath, wear gloves. (Courtesy Marjorie Pyle, RNC, Lifecircle, 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: microcephaly
Hydrocephaly: sutures
widely separated, circumference 4 cm more than
chest circumference
Increased intracranial
pressure
Maternal rubella, toxoplasmosis, cytomegalic inclusion disease, fused

cranial sutures
(craniosynostosis)
Maldevelopment, infection
Hemorrhage, spaceoccupying lesion
Circumference of head. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Continued
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THE NEWBORN
TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
30 cm
Prematurity
CHEST CIRCUMFERENCE
Measure at nipple line
2-3 cm less than head circumference, averages between 30 and 33 cm
Circumference of chest. (Courtesy Marjorie Pyle, RNC, Lifecircle,

Costa Mesa, CA.)
ABDOMINAL CIRCUMFERENCE
Measure above umbilicus

Not usually measured unless specific indication
Same size as chest
Enlarging abdomen between feedings
Abdominal mass or blockage in intestinal tract
Abdominal circumference. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
SKIN
Color
Generally pink
Varying with ethnic origin
Acrocyanosis, especially if
chilled
Mottling
Harlequin sign
Plethora
Telangiectases (stork
bites or capillary hemangiomas)
Erythema toxicum or
neonatorum (newborn
rash)
Milia
Dark red
Gray
Pallor
Cyanosis
Prematurity, polycythemia
Hypotension, poor
perfusion
Cardiovascular problem,
CNS damage, blood
dyscrasia, blood loss,
twin-to-twin transfusion,
nosocomial infection
Hypothermia, infection, hypoglycemia, cardiopulmonary diseases, cardiac,
neurologic, or respiratory
malformations
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TABLE 19-2

AREA ASSESSED
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
Petechiae over presenting

part
Ecchymoses from forceps in
vertex births or over buttocks, genitalia, and legs
in breech births
None at birth
Physiologic jaundice in up
to 50% of term infants in
first week of life
Petechiae over any other

area
Ecchymoses in any other
area
Clotting factor deficiency,

infection
Hemorrhagic disease, traumatic birth
Jaundice within first 24 hr
Increased hemolysis, Rh
isoimmunization, ABO
incompatibility
Mongolian spot (see Fig.

18-6)
Infants of AfricanAmerican, Asian, and
Native American origin:
70%-85%
Infants of Caucasian
origin: 5%-13%
No skin edema
Hemangiomas
Nevus flammeus: portwine stain
Nevus vasculosus: strawberry mark
Cavernous hemangiomas
NORMAL FINDINGS
SKINcontd
Jaundice
Birthmarks
Check condition
Opacity: few large blood

vessels visible indistinctly
over abdomen
Gently pinch skin between

thumb and forefinger
over abdomen and inner
thigh to check for turgor
Vernix caseosa:
Color and odor
Dehydration: loss of weight

best indicator
After pinch released, skin
returns to original state
immediately
Normal weight loss after
birth: 10% of birth
weight
Possibly puffy
Whitish, cheesy, odorless;
usually more found in
creases, folds
Edema on hands, feet; pitting over tibia

Texture thin, smooth, or of
medium thickness; rash
or superficial peeling
visible
Numerous vessels very visible over abdomen
Texture thick, parchmentlike; cracking, peeling
Skin tags, webbing
Papules, pustules, vesicles,
ulcers, maceration
Loose, wrinkled skin
Tense, tight, shiny skin

Lack of subcutaneous fat,
prominence of clavicle
or ribs
Absent or minimal
Excessive
Green color
Odor
Lanugo
Over shoulders, pinnas of

ears, forehead
Absent
Excessive
Overhydration
Prematurity, postmaturity
Prematurity
Postmaturity
Impetigo, candidiasis,
herpes, diaper rash
Prematurity, postmaturity,
dehydration: fold of skin
persisting after release of
pinch
Edema, extreme cold,
shock, infection
Prematurity, malnutrition
Postmaturity
Prematurity
Possible in utero release of
meconium or presence of
bilirubin
Possible intrauterine
infection
Postmaturity
Prematurity, especially if
lanugo abundant and
long and thick over back
Continued
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THE NEWBORN
TABLE 19-2

AREA ASSESSED
DEVIATIONS FROM
NORMAL RANGE
NORMAL FINDINGS
ETIOLOGY
HEAD
Fontanels
Open vs closed
Sutures
Hair
Making up one fourth of

body length
Molding
Caput succedaneum, possibly showing some ecchymosis
Anterior fontanel 5 cm diamond, increasing as
molding resolves
Posterior fontanel triangle,
smaller than anterior
Palpable and unjoined sutures
Possible overlap of sutures
with molding
Silky, single strands lying
flat; growth pattern toward face and neck, variation in amount
Cephalhematoma
Molding
Severe molding
Indentation
Depressed
Birth trauma
Fracture from trauma
Tumor, hemorrhage,
infection
Malnutrition, hydrocephaly,
retarded bone age, hypothyroidism
Dehydration
Widely spaced
Hydrocephaly
Premature closure
Craniosynostosis
Fine, woolly
Unusual swirls, patterns,
hairline or coarse, brittle
Prematurity
Endocrine or genetic
disorders
Full, bulging
Large, flat, soft
EYES
Eyeballs
Both present and of equal

size, both round, firm
Eyes and space between
eyes each one third the
distance from outer-toouter canthus
Epicanthal folds: normal
racial characteristic
Symmetric in size, shape
Blink reflex
No discharge
No tears
Subconjunctival hemorrhage
Agenesis or absence of one

or both eyeballs
Epicanthal folds when present with other signs
Discharge: purulent
Small eyeball
Lens opacity or absence of
red reflex
Discharge (purulent)
Chemical conjunctivitis
Lesions: coloboma, absence
of part of iris
Pink color of iris
Jaundiced sclera
Chromosomal disorders
such as Down, cri-du-chat
syndromes
Infection
Rubella syndrome
Congenital cataracts, possibly from rubella
Infection
Eye medication (requires no
treatment)
Congenital
Albinism
Hyperbilirubinemia
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.
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TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
EYEScontd
Pupils
Eyeball movement
Eyebrows
Present, equal in size, reactive to light

Random, jerky, uneven, focus possible briefly, following to midline
Transient strabismus or nystagmus until third or
fourth month
Distinct (not connected in
midline)
Pupils: unequal, constricted,

dilated, fixed
Persistent strabismus
Dolls eyes
Connection in midline
Cornelia de Lange syndrome
Midline
Some mucus but no
drainage
Preferential nose breather
Sneezing to clear nose
Slight deformity (flat or deviated to one side) from
passage through birth
canal
Copious drainage, with or

without regular periods of
cyanosis at rest and return of pink color with
crying
Malformed
Choanal atresia, congenital

syphilis
Correct placement: line

drawn through inner and
outer canthi of eyes
reaching to top notch of
ears (at junction with
scalp)
Well-formed, firm cartilage
Agenesis
Lack of cartilage
Low placement
Sunset
Intracranial pressure, medications, tumors

pressure
pressure
NOSE
Flaring of nares
Congenital syphilis,
chromosomal disorder
EARS
Pinna
Hearing
Responds to voice and

other sounds
State (e.g., alert, asleep)
influences response
Prematurity
Chromosomal disorder,
mental retardation, kidney disorder
Preauricular tags
Size: possibly overly prominent or protruding ears
No response to sound
Deaf, rubella syndrome
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 Johnson Nutritionals, Evansville, IN.)
Continued
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THE NEWBORN
TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
FACIES
Normal appearance, wellplaced, proportionate,

symmetric features
Positional deformities
Infant appearance odd or

funny
Usually accompanied by
other features such as
low-set ears, other structural disorders
Symmetry of lip movement

Dry or moist
Pink
Gross anomalies in placement, size, shape

Cyanosis, circumoral pallor
Transient circumoral
cyanosis
Pink gums
Inclusion cysts (Epstein
pearlsBohn nodules,
whitish, hard nodules on
gums or roof of mouth)
Tongue not protruding,
freely movable, symmetric in shape, movement
Sucking pads inside cheeks
Asymmetry in movement of
lips
Teeth: predeciduous or
deciduous
Hereditary, chromosomal
aberration
MOUTH
Lips
Buccal mucosa
Gums
Cleft lip and/or palate, gums

Respiratory distress, hypothermia
Cranial nerve VII paralysis
Hereditary
Prematurity, chromosomal
disorder
Candida albicans
Soft and hard palates intact
Macroglossia
Short lingual frenulum
Thrush: white plaques on
cheeks or tongue that
bleed if touched
Cleft hard or soft palate
Chin
Uvula in midline
Epstein pearls
Distinct chin
Micrognathia
Saliva
Mouth moist
Excessive saliva
Reflexes present
Reflex response dependent
on state of wakefulness
and hunger
Absent
Pierre Robin or other

syndrome
Esophageal atresia, tracheoesophageal fistula
Prematurity
Short, thick, surrounded by

skin folds; no webbing
Head held in midline (sternocleidomastoid muscles
equal), no masses
Transient positional
deformity
Freedom of movement from
side to side and flexion
and extension, no movement of chin past shoulder
Thyroid not palpable
Webbing
Restricted movement, holding of head at angle
Absence of head control
Turner syndrome
Torticollis (wryneck),
opisthotonos
Prematurity, Down syndrome
Masses
Distended veins
Enlarged thyroid
Cardiopulmonary disorder
Bulging of chest, unequal

movement
Malformation
Pneumothorax, pneumomediastinum
Funnel chestpectus
excavatum
Tongue
Palate (soft, hard):

Arch
Uvula
Reflexes:
Rooting
Sucking
Extrusion
NECK
Sternocleidomastoid
muscles
Thyroid gland
CHEST
Thorax
Almost circular, barrel

shaped
Tip of sternum possibly
prominent
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TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
CHESTcontd
Respiratory movements
Clavicles
Ribs
Nipples
Breast tissue
Symmetric chest movements, chest and abdominal movements synchronized during respirations
Occasional retractions, especially when crying
Clavicles intact
Rib cage symmetric, intact;
moves with respirations
Prominent, well formed;
symmetrically placed
Breast nodule: approximately

3-10 mm in term infant
Maternal hormones
Secretion of witchs milk
Retractions with or without

respiratory distress
Prematurity, RDS
Fracture of clavicle; crepitus

Poor development of rib
cage and musculature
Supernumerary, along nipple line
Malpositioned or widely
spaced
Lack of breast tissue
Trauma
Prematurity
One artery
Meconium stained
Bleeding or oozing around
cord
Redness or drainage around
cord
Herniation of abdominal
contents into area of cord
(e.g., omphalocele); defect covered with thin, friable membrane, possibly
extensive
Gastroschisis: fissure of abdominal cavity
Renal anomalies
Intrauterine distress
Hemorrhagic disease
Distention at birth
Ruptured viscus, genitourinary masses or malformations: hydronephrosis, teratomas, abdominal tumors

Overfeeding, high gastrointestinal tract obstruction
Lower gastrointestinal tract
obstruction, imperforate
anus
Overfeeding
Stenosis of bowel
Obstruction
Prematurity
ABDOMEN
Umbilical cord
Abdomen
Two arteries, one vein

Whitish gray
Definite demarcation between cord and skin, no
intestinal structures
within cord
Dry around base, drying
Odorless
Cord clamp in place for 24 hr
Reducible umbilical hernia
Rounded, prominent, dome

shaped because abdominal musculature not fully
developed
Some diastasis of abdominal musculature
Liver possibly palpable
1-2 cm below right costal
margin
No other masses palpable
No distention
Mild
Marked
Intermittent or transient
Partial intestinal obstruction
Visible peristalsis
Malrotation of bowel or adhesions
Sepsis
Infection, possible persistence of urachus
Infection
Continued
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TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
ABDOMENcontd
Bowel sounds
Stools
Color
Movement with respiration
Sounds present within

minutes after birth in
healthy term infants
Meconium stool passing
within 24-48 hr after
birth
Linea nigra possibly
apparent
Respirations primarily diaphragmatic, abdominal
and chest movement synchronous
Scaphoid, with bowel

sounds in chest and respiratory distress
No stool
Female genitals
Ambiguous genitals
enlarged clitoris with urinary meatus on tip, fused
labia
Virilized female; extremely
large clitoris
Decreased abdominal
breathing
Seesaw
Diaphragmatic hernia
Imperforate anus
Hormone influence during

pregnancy
Intrathoracic disease,
phrenic nerve palsy, diaphragmatic hernia
GENITALIA
Female
Clitoris
Labia majora
Labia minora
Discharge
Vagina
Urinary meatus
Male
Penis
Urinary meatus as slit
Prepuce
Usually edematous
Usually edematous, covering labia minora in term
newborns
Increased pigmentation
Edema and ecchymosis
Possible protrusion over
labia majora
Smegma
Open orifice
Some vernix caseosa between labia possible
Blood-tinged discharge
from pseudomenstruation caused by pregnancy
hormones
Mucoid discharge
Hymenal or vaginal tag
Beneath clitoris, difficult to
see (to watch for voiding)
Male genitals
Meatus at tip of penis

Prepuce (foreskin) covering
glans penis and not retractable
Labia majora widely separated and labia minora

prominent
Chromosomal disorder, maternal drug ingestion
Congenital adrenal hyperplasia
Pregnancy hormones
Breech birth
Prematurity
Absence of vaginal orifice
Fecal discharge
Fistula
Stenosed meatus
Bladder extrophy
Increased size and pigmentation caused by pregnancy hormones

Urinary meatus not on tip of
glans penis
Prepuce removed if circumcised
Wide variation in size of
genitals
Ambiguous genitals
Hypospadias, epispadias
Round meatal opening
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19
573
TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
GENITALIAcontd
Malecontd
Scrotum
Rugae (wrinkles)
Testes
Check urination
Check reflex
Cremasteric
Large, edematous, pendulous in term infant; covered with rugae
Palpable on each side

Voiding within 24 hr, stream
adequate, amount adequate
Rust-stained urine
Testes retracted, especially
when newborn is chilled
Scrotal edema and ecchymosis if breech birth

Scrotum smooth and testes
undescended
Hydrocele, small, noncommunicating
Inguinal hernia
Bulge palpable in inguinal
canal
Undescended
Uric acid crystals*
Prematurity, cryptorchidism
Prematurity
EXTREMITIES
Degree of flexion
Range of motion
Symmetry of motion
Muscle tone
Arms and hands
Intactness
Appropriate placement
Color
Fingers
Joints
Grasp (palmar and plantar)
Humerus
Legs and feet
Assuming of position maintained in utero

Transient (positional) deformities
Attitude of general flexion
Full range of motion, spontaneous movements
Longer than legs in newborn period
Contours and movement
symmetric
Slight tremors sometimes
apparent
Some acrocyanosis, especially when chilled
Five on each hand
Fist often clenched with
thumb under fingers
Full range of motion, symmetric contour

Intact
Appearance of bowing because lateral muscles
more developed than medial muscles
Feet appearing to turn in
but can be easily rotated
externally, positional defects tending to correct
while infant is crying
Acrocyanosis
Limited motion
Poor muscle tone
Positive scarf sign
Asymmetry of movement
Asymmetry of contour
Amelia or phocomelia
Palmar creases
Simian line with short, incurved little fingers
Malformations
Prematurity, maternal medications, CNS anomalies
Fracture or crepitus,
brachial nerve trauma,
malformations
Malformations, fracture
Teratogens
Down syndrome
Webbing of fingers: syndactyly

Absence or excess of fingers
Strong, rigid flexion; persistent fists; positioning
of fists in front of mouth
constantly
Increased tonicity, clonus,
prolonged tremors
Fractured humerus
Amelia (absence of limbs),
phocomelia (shortened
limbs)
Familial trait
Temperature of one leg different from that of the

other
Circulatory deficiency CNS

disorder
CNS disorder
CNS disorder
Trauma
Chromosomal deficiency,
teratogenic effect
*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.
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TABLE 19-2

AREA ASSESSED
NORMAL FINDINGS
DEVIATIONS FROM
NORMAL RANGE
ETIOLOGY
EXTREMITIEScontd
Toes
Five on each foot
Webbing, syndactyly
Absence or excess of digits
Femur
Intact femur
No click heard, femoral
head not overriding acetabulum
Major gluteal folds even
Soles well lined (or wrinkled) over two thirds of
foot in term infants
Plantar fat pad giving flatfooted effect
Full range of motion, symmetric contour
Femoral fracture
Developmental dysplasia or
dislocation
Soles of feet
Joints
Chromosomal defect
Chromosomal defect, familial trait
Difficult breech birth
Soles of feet
Few lines
Covered with lines
Congenital clubfoot
Prematurity
Postmaturity
Hypermobility of joints
Asymmetric movement
Down syndrome
Trauma, CNS disorder
Limitation of movement
Fusion or deformity of vertebra
Spina bifida cystica
Meningocele,
myelomeningocele
Often associated with spina
bifida occulta
BACK
Spine
Shoulders
Scapulae
Iliac crests
Spine straight and easily

flexed
Infant able to raise and support head momentarily
when prone
Temporary minor positional
deformities, correction
with passive manipulation
Shoulders, scapulae, and iliac crests lining up in
same plane
Base of spinepilonidal
area
Pigmented nevus with tuft

of hair
ANUS
Patency
Sphincter response (active
wink reflex)
One anus with good sphincter tone

Passage of meconium
within 24-48 hr after birth
Good wink reflex of anal
sphincter
Low obstruction: anal membrane

High obstruction: anal or
rectal atresia
Absence of anal opening
Drainage of fecal material
from vagina in female or
urinary meatus in male
Meconium followed by transitional and soft yellow

stools
No stool
Frequent watery stools
Rectal fistula
STOOLS
Frequency, color, consistency
Obstruction
Infection, phototherapy
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BOX 19-2
Significance of the Apgar Score

The Apgar score was developed to provide a systematic
method of assessing an infants condition at birth. Researchers have tried to correlate Apgar scores with various 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 predicted 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 ascertain 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 consistency in the assigned scores limits studies of the Apgars long-term predictive value. Prospective parents and
the public need education on the significance of the Apgar 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. Attorneys 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 significance, 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 longterm significance. Journal of Perinatal Education, 9(3), 5-9.
19
BOX 19-3
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 immediately after birth
If formula feeding, give formula of mothers choice
q3-4 hr on demand
Allow rooming-in as desired and infants condition
permits
Newborn screening panel per state health department protocol (phenylketonuria [PKU], thyroxine [T4],
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 following:
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 mothers abdomen to allow skin-to-skin contact. This contributes to maintenance of the infants optimum 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 mothers abdomen
or in her arms immediately after birth. Efforts should be directed 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 until after the parents have had an opportunity to interact with
the infant. Routine procedures and the admission process can
be carried out in the mothers room or in a separate nursery.
Box 19-3 shows an example of newborn routine orders.
575
Ineffective airway clearance related to

airway obstruction with mucus, blood, and amniotic 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 viral 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 infant care activities
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Procedure
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 infants
mouth is avoided because this could stimulate the
gag reflex.
The nasal passages are suctioned one nostril at a time.
When the infants 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 infants crib.
The parents should be given demonstrations on how
to use the bulb syringe and asked to perform a
return demonstration.
Fig. 19-2
insertion.
Bulb syringe. Bulb must be compressed before
State understanding of biologic and behavioral characteristics 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 implementation of appropriate care.
Identification
Information on the matching identification bracelets applied 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 identification number, according to hospital protocol. Infants
also are footprinted by using a form that includes the
mothers 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 little difficulty clearing the airway. Most secretions are moved
by gravity and brought to the oropharynx by the cough reflex. The infant is often maintained in a side-lying position
(head stabilized, not in Trendelenburg) with a rolled blanket 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 perform gentle percussion over the chest wall using a soft circular 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 infants tolerance to the procedure carefully evaluated (Hagedorn, Gardner, & Abman,
Fig. 19-3 Chest percussion. Nurse performs gentle percussion 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 secretions by gasping as the nares are touched. The bulb is compressed and inserted into one side of the mouth. The center 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 infants
crib. The parents should be given a demonstration of how
to use the bulb syringe and asked to perform a return demonstration.
Use of nasopharyngeal catheter with mechanical suction apparatus. Deeper suctioning may
be needed to remove mucus from the newborns nasopharynx 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-
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Procedure
Suctioning with a Nasopharyngeal
Catheter with Mechanical Suction
Apparatus
To remove excessive or tenacious mucus from the infants
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 laryngospasms 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 infants cry sounds
clear and air entry into the lungs is heard by
stethoscope.
ringe eliminates the problem. The infant should be positioned with the head slightly lower than the body to facilitate gravity drainage. The nurse also should listen to the infants 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 after 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, mechanical suction can be used.
If the newborn has an obstruction that is not cleared with
suctioning, further investigation must be performed to determine if there is a mechanical defect (e.g., tracheoesophageal 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 effective cardiac function
Adequate thermoregulation (exposure to cold stress increases 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 optimal 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 newborns
body temperature include placing the infant directly on the
mothers abdomen and covering with a warm blanket (skin-
19
577
signs of
POTENTIAL COMPLICATIONS
Abnormal Newborn Breathing
Bradypnea: respirations (25/min)

Tachypnea: 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 temperature stabilizes. The infants 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 37C. This setting should maintain the healthy newborns skin temperature at approximately 36.5 to 37C. A
thermistor probe (automatic sensor) is taped to the right upper 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 warming. This will ensure detection of minor changes resulting
from external environmental factors or neonatal factors (peripheral vasoconstriction, vasodilation, or increased metabolism) before a dramatic change in core body temperature develops. The servocontroller adjusts the warmer
temperature to maintain the infants skin temperature within
the present range. The sensor must be checked periodically
to make sure it is securely attached to the infants skin. The
axillary temperature of the newborn is checked every hour
(or more often as needed) until the newborns temperature
stabilizes. The time to stabilize and maintain body temperature 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 minimized for the newborn; therefore examinations and activities are performed with the newborn under a heat panel. The
initial bath is postponed until the newborns skin temperature is stable and can adjust to heat loss from a bath. The
exact and optimal timing of the bath for each newborn remains 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 immediately after birth may cause the newborns temperature to
fall below the normal range (hypothermia). Warming the
hypothermic infant is accomplished with care. Rapid warming may cause apneic spells and acidosis in an infant. The
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warming process is monitored to progress slowly over a period of 2 to 4 hours.

Therapeutic interventions
It is the nurses responsibility to perform certain interventions 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 newborn during passage through the mothers birth canal. The
agent used for prophylaxis varies according to hospital protocols, 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 informed refusal form, and their refusal will be noted in the
infants 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.
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 Neisseria 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 conjunctival 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 inner 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 sulfonamide 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 infants intestines are not yet colonized by microflora that synthesize vitamin K. Administering vitamin
K intramuscularly is routine in the newborn period. A single 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).
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.)
NURSE ALERT Vitamin K is never administered by the intravenous route for prevention of hemorrhagic disease
of the newborn except in some cases of a preterm infant who has no muscle mass. In such cases, the medication should be diluted and given over 10 to 15 minutes, with the infant being closely monitored with a
cardiorespiratory monitor. Rapid bolus administration
of vitamin K may cause cardiac arrest.
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19
579
Medication Guide
Vitamin K: Phytonadione
(AquaMEPHYTON, Konakion)
ACTION
This intervention provides vitamin K because the newborn 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 hemorrhagic disease in the newborn.
NEONATAL DOSAGE
Administer a 0.5- to 1-mg (0.25- to 0.5-ml) dose intramuscularly within 2 hr of birth; may be repeated if newborn 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.
Wear gloves. Administer in the middle third of the vastus lateralis muscle by using a 25-gauge, 5 8-inch needle. Inject into skin that has been cleaned, or allow alcohol 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. Insert 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 immediately after birth. The goal of cord care is to prevent or decrease 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).
NURSE ALERT If bleeding from the blood vessels of the
cord is noted, the nurse checks the clamp (or tie) and applies a second clamp next to the first one. If bleeding
is not stopped immediately, the nurse calls for assistance.
Hospital protocol directs the time and technique for routine cord care. Many hospitals have subscribed to the practice of dry care consisting of cleaning the periumbilical area
with soap and water and wiping it dry. Others apply an antiseptic solution such as Triple Dye or alcohol to the cord
(Janssen, Selwood, Dobson, Peacock, & Thiessen, 2003). Current recommendations for cord care by the Association of
Womens 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
Fig. 19-5 With special scissors, remove clamp after cord

dries (about 24 hours). (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
the cord should be assessed for edema, redness, and purulent drainage with each diaper change. The cord clamp is removed after 24 hours when the cord is dry (Fig. 19-5). Cord
separation time is influenced by a number of factors, including type of cord care, type of birth, and other perinatal events. The average cord separation time is 10 to 14 days.
Promoting parent-infant interaction
Todays 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 begins as the infant ingests flora from the mothers colostrum.
Evaluation
Evaluation of the effectiveness of immediate care of the newborn is based on the previously stated outcomes.
CARE MANAGEMENT: FROM
2 HOURS AFTER BIRTH UNTIL
DISCHARGE
The infants 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 variations 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
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EVIDENCE-BASED PRACTICE
Optimum Duration of Exclusive Breastfeeding: Systematic World Health
Organization Review
BACKGROUND
Statistical Analyses
Breastfeeding provides many documented health benefits and can be lifesaving in developing countries. Breastfeeding has a protective effect against gastrointestinal and
respiratory infection, sudden infant death syndrome
(SIDS), atopic disease, obesity, diabetes, Crohns disease,
and lymphoma. Breastfeeding may accelerate neurocognitive development and achievement. Maternal
health benefits include possible protection against
breast cancer, ovarian cancer, and osteoporosis.
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 weanlings dilemma stemmed from questions
about inadequate breast milk nutrition versus nutritionally inadequate or contaminated weaning foods. WHO requested this review of available evidence regarding the
optimum duration of breastfeeding.
FINDINGS
All agreed that exclusive breastfeeding was best for 3 to

4 months. The reviewers compared health, growth, and
development outcomes for those who continued exclusive breastfeeding until 6 months, versus those who gradually added supplemental liquid or food to breastfeeding.
The participants could all be healthy, singleton, term infants (low birth weight accepted, as long as gestationally
full term). Infant outcome measures could include
weight, length, head circumference, infections, morbidity, mortality, micronutrient status, neuromotor and cognitive developmental milestones, atopic disease, type
1 diabetes, blood pressure, adult chronic illnesses, and
inflammatory and autoimmune diseases. Maternal outcome measures include postpartum weight loss, lactational amenorrhea, breast and ovarian cancer, and osteoporosis.
The authors found no significant difference in weight,

length, or atopic disease in the two groups. Exclusively
breastfed infants had significantly decreased gastrointestinal infections. There was a marginally significant decrease in the iron stores of exclusively breastfed infants
in developing countries at 6 months, unless they were receiving an iron supplement. Maternal weight loss was accelerated in exclusive breastfeeding, and lactational
amenorrhea was prolonged.
LIMITATIONS
OBJECTIVES
Statistical analyses were possible in only the two controlled trials. The observational studies were too heterogeneous and limited by design to pool data.
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 causality. 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.
CONCLUSIONS
The researchers found no evidence of a weanlings

dilemma, and no benefits from adding supplemental
food between 4 and 6 months. The iron deficit of exclusively breastfed babies in developing countries can be
corrected with infant drops and does not warrant the loss
of protection against gastrointestinal and respiratory infections that exclusive breastfeeding confers. Maternal
lactational amenorrhea provides contraceptive benefit for
child spacing. Rapid postpartum weight loss may not benefit 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 ReviewsBest Evidence, SocioFile, CAB Abstracts, EMBASEPsychology,
EconLit, Index Medicus for the WHO Eastern Mediterranean, African Index Medicus, and LILACS Latin American and Caribbean literature. Search keywords included
exclusive breastfeeding and growth.
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.
Exclusive breastfeeding should be recommended. Iron

supplements for breastfeeding infants are beneficial. The
contraceptive benefits of lactational amenorrhea are important.
IMPLICATIONS FOR FURTHER RESEARCH
Public health policy demands information about breastfeeding beyond the observational stage. Large, randomized trials are needed, especially in developing countries,
to confirm infection morbidity and infant nutritional status 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.
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assessment of weight and measurement (i.e., circumference

of head and chest, length), instillation of eye medications,
intramuscular administration of vitamin K, and physical assessment, may be carried out in the labor and birth unit.
Nurses who work in an SRMC unit; labor, delivery, and recovery (LDR) room; or labor, delivery, recovery, and postpartum (LDRP) room must be knowledgeable and competent in intrapartal, neonatal, and postpartum nursing care.
If an infant is transferred to the nursery, the infants identification is verified by the nurse receiving the infant, who
places the baby in a warm environment and begins the admission 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 parentinfant bonding while still allowing the new parents some
time to be alone.
Assessment
Gestational age assessment
Assessment of gestational age is an important criterion because perinatal morbidity and mortality rates are related to
gestation age and birth weight. The simplified Assessment
of Gestational Age (Ballard, Novak, & Driver, 1979) is commonly used to assess gestational age of infants between
35 and 42 weeks. It assesses six external physical and six neuromuscular signs. Each sign has a number score, and the cumulative score correlates with a maturity rating of 26 to
44 weeks of gestation. The score is accurate to plus or minus 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 gestation. The tool has the same physical and neuromuscular sections but includes 1 to 2 scores that reflect signs of
extremely premature infants, such as fused eyelids; imperceptible 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 infants with a gestational age of 26 weeks or less should be performed 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 accuracy, it is recommended that the initial examination be
performed within the first 48 hours of life. Neuromuscular
adjustments after birth in extremely immature neonates require that a follow-up examination be performed to further
validate neuromuscular criteria. The scale overestimates gestational 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
19
581
for predicting mortality risks and providing guidelines for

management of the neonate than estimating gestational age
or birth weight alone. The infants 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, postterm, or postmature newborns also may be outside these
normal ranges. Birth weights are classified in the following 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 between the 10th and 90th percentile for infants 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 expected rate of intrauterine growth or a shortened gestation period. Preterm birth and LBW commonly occur 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 prematureBorn before completion of
37 weeks of gestation, regardless of birth weight
TermBorn between the beginning of week 38 and the
end of week 42 of gestation
Postterm (postdate)Born after completion of week
42 of gestation
PostmatureBorn after completion of week 42 of gestation and showing the effects of progressive placental insufficiency
Maternal effects on gestational age assessment and birth weight. Some maternal conditions
can affect the results of the gestational assessment. For instance, any infant who has had oxygen deprivation during
labor will show poor muscle tone. Infants in respiratory distress tend to be flaccid and assume a frog-leg posture. Even
though an infant may look large, such as the infant of a diabetic 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 examination encourages discussion of parental concerns and
actively involves the parents in the health care of their infant
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from birth. It also affords the nurse an opportunity to observe 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 radiant warmer. The physical assessment should begin with a review 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, vital signs measurement, and parent-infant interactions. The
assessment should progress systematically from head to toe,
with assessment and evaluation of each system (i.e., cardiovascular, respiratory, and so on). Descriptions of any variations from normal findings and all abnormal findings are
included. The findings provide a database for implementing
the nursing process with newborns and providing anticipatory 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
neonates maturity level can be gauged by assessment of general appearance. Features to assess in the general survey include 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 flexion. 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 unless cardiac problems are suspected. An irregular, very slow,
or very fast heart rate may indicate a need for BP measurements.
The axillary temperature is a safe, accurate substitute for
the rectal temperature. Electronic thermometers have expedited this task and provide a reading within 1 minute. Taking an infants temperature may cause the infant to cry and
struggle against the placement of the thermometer in the axilla. Tympanic thermometers may be used after the newborns 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 after 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 irregular. It is important to count the respirations for a full minute
to obtain an accurate count because of normal short periods of apnea. The examiner also should observe for symmetry of chest movements (see Table 19-2 for normal respiratory rates).
Apical pulse rates should be obtained for all infants. Auscultation 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 transmission of respiratory sounds. However, the first (S1) and second (S2) sounds should be clear and well defined; the second 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 murmurs 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 facilitates 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 between 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 neonates head an asymmetric appearance (see Fig. 18-9). Parents should be reassured that this
will go away and that nothing need be done to the head. Facial 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 finger of the examiner. At the same time the suck reflex can be
assessed.
A gross assessment of hearing can be done by watching
the neonates 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 fingers slowly over the anterior clavicular surface. If a mass or
lump is detected, the examiner tries to move the neonates
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 palpation. 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 between 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-
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19
583
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 affected 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 newborns reflexes (see
Table 18-3) provides useful information about the infants
nervous system and state of neurologic maturation. The assessment must be carried out as early as possible because abnormal signs present in the early neonatal period may disappear. They may reappear months or years later as abnormal
functions.
Common problems in the newborn
Physical injuries. Birth trauma includes any physical 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 require 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 presentation, and congenital anomalies. Injury can be the result of obstetric birth techniques such as forceps-assisted
birth, vacuum extraction, version and extraction, and cesarean birth (Efird & Hernandez, 2005).
Soft tissue injuries. Cephalhematoma is the most
common type of cranial injury in newborns and can be associated with an underlying skull fracture. Caput succeda-
Fig. 19-6 Marked bruising on the entire face of an infant

born vaginally after face presentation. Less severe ecchymoses were present on the extremities. Phototherapy was required for treatment of jaundice resulting from the breakdown
of accumulated blood. (From ODoherty, N. [1986]. Neonatology: Micro atlas of the newborn. Nutley, NJ: HoffmanLaRoche.)
Fig. 19-7 Swelling of the genitals and bruising of the buttocks after a breech birth. (From ODoherty, N. [1986]. Neonatology: Micro atlas of the newborn. Nutley, NJ: HoffmanLaRoche.)
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 fetal head (Efird & Hernandez, 2005). Caput succedaneum and
cephalhematoma are described in Chapter 18 (see Fig. 18-5).
Subconjunctival and retinal hemorrhages result from rupture 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 resolve without sequelae.
Erythema, ecchymoses, petechiae, abrasions, lacerations,
or edema of buttocks and extremities may be present. Localized 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 presentation (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. Petechiae (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 ExerciseJaundice
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THE NEWBORN
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 forceps injury, commonly a linear mark appears across both
sides of the face in the shape of the forceps blades. The affected 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 during 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 associated 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, although the arm and shoulder may be immobilized for comfort (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 infants 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 forceps (Fig. 19-8). The location of a skull fracture determines
Fig. 19-8 Depressed skull fracture in a term male after

rapid (1-hour) labor. The infant was delivered by occiputanterior 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 nonsurgical 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 & Hernandez,
2005).
Parents need emotional support when it comes to handling a newborn with birth injuries because they are often
fearful of hurting their newborn. Parents are encouraged to
practice handling, changing, and feeding the injured newborn under the guidance of the nursing staff. This increases
the parents knowledge and confidence, in addition to facilitating attachment. A plan for follow-up therapy is developed with the parents so that the times and arrangements
for therapy are convenient for them.
Physiologic problems
Physiologic jaundice. The majority of term newborns
have some degree of physiologic jaundice (become yellowish) during the first 3 days of life (see Chapter 18). Jaundice
is clinically visible when serum bilirubin levels reach
5 to 7 mg/dl.
Every newborn is assessed for jaundice. The blanch test
helps differentiate cutaneous jaundice from skin color. To
do the test, apply pressure with a finger over a bony area (e.g.,
the nose, forehead, sternum) for several seconds to empty
all the capillaries in that spot. If jaundice is present, the
blanched area will look yellow before the capillaries refill.
The conjunctival sacs and buccal mucosa also are assessed,
especially in darker-skinned infants. It is better to assess for
jaundice in daylight, because artificial lighting and reflection
from nursery walls can distort the actual skin color.
Jaundice is noticeable first in the head and then progresses
gradually toward the abdomen and extremities because of
the newborn infants circulatory pattern (cephalocaudal developmental progression). If jaundice is suspected, evaluation of serum bilirubin level is needed. Jaundice that appears
before the infant is 24 hours old is likely to be pathologic
instead of physiologic, and the primary health care
provider should be notified.
Hypoglycemia. Hypoglycemia during the early newborn period of a term infant is defined as a blood glucose
concentration of less than 35 mg/dl or as a plasma concentration of less than 40 mg/dl. When the neonate is born
and abruptly disconnected from the continuous supply of
maternal glucose, there is a period of adjustment as the newborn begins to regulate blood glucose concentration in accordance with intermittent feedings. Hypoglycemia can result if this metabolic adaptation is delayed, if early feedings
result in limited intake, or if the neonate is stressed. The glucose level normally declines during the first hours after birth.
Not all newborns are routinely screened for hypoglycemia.
Instead, those who are symptomatic and those considered
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to be at risk for hypoglycemia are tested. Risk factors for hypoglycemia include birth weight less than 2500 g or greater
than 4000 g, gestational age less than 37 weeks or greater than
42 weeks, LGA infant, SGA infant, maternal diabetes, and
5-minute APGAR of 5 or less. Blood glucose levels should
be checked initially between 30 minutes and 2 hours of life,
and repeated every 30 minutes to 1 hour until the levels are
consistently within normal limits. Glucose levels may be
measured every 4 hours until the risk period has passed
(Townsend, 2005).
Signs of hypoglycemia include jitteriness; an irregular respiratory effort; cyanosis; apnea; a weak, high-pitched cry;
feeding difficulty; hunger; lethargy; twitching; eye rolling;
and seizures. The signs may be transient and recurrent.
Hypoglycemia in the low risk term infant is usually eliminated by feeding the infant. Occasionally the intravenous
administration of glucose is required for newborns with persistently high insulin levels or those with depleted glycogen
stores.
Hypocalcemia. Hypocalcemia (serum calcium levels
of less than 7.8 to 8 mg/dl in term infants and 7 mg/dl in
preterm infants) may occur in newborns of diabetic mothers or in those who had perinatal asphyxia or trauma, and
in LBW and preterm infants. Early-onset hypocalcemia occurs within the first 72 hours after birth. Signs of hypocalcemia include jitteriness, high-pitched cry, irritability, apnea,
intermittent cyanosis, abdominal distention, and laryngospasm, although some hypocalcemic infants are asymptomatic (Blackburn, 2003).
In most instances, early-onset hypocalcemia is selflimiting and resolves within 1 to 3 days. Treatment includes
early feeding and, occasionally, the administration of calcium
supplements. Preterm or asphyxiated infants may require intravenous elemental calcium.
Jitteriness is a symptom of both hypoglycemia and
hypocalcemia; therefore hypocalcemia must be considered
if the therapy for hypoglycemia proves ineffective. In many
newborns, jitteriness remains despite therapy and cannot be
explained by hypoglycemia or hypocalcemia (DeMarini &
Tsang, 2002).
Laboratory and diagnostic tests
Because newborns experience many transitional events in
the first 28 days of life, laboratory samples are often gathered to determine adequate physiologic adaptation and to
identify disorders that may adversely affect the childs life
beyond the neonatal period. Tests that are commonly performed include blood glucose levels, bilirubin levels, complete blood count (CBC), newborn screening tests, and drug
tests. Standard laboratory values for a term newborn are
given in Box 19-4.
Newborn genetic screening. Before hospital discharge, a heel-stick blood sample is obtained to detect a variety of congenital conditions. Mandated by U.S. law, newborn genetic screening is an important public health program
that is aimed at early detection of genetic diseases that re-
19
585
sult in severe health problems if not treated early. All states

screen for phenylketonuria (PKU) and hypothyroidism, but
each state determines whether other tests are performed.
Other genetic defects that are included in some screening
programs include galactosemia, cystic fibrosis, maple syrup
urine disease, and sickle cell disease. It is recommended that
the screening test be repeated at age 1 to 2 weeks if the initial specimen was obtained when the infant was younger
than 24 hours (Albers & Levy, 2005; Zinn, 2002).
Newborn hearing screening. Universal newborn
hearing screening is required by law in over 30 states and is
performed routinely in other states. Infants in the neonatal
intensive care unit (NICU) and those with other risk factors
are screened in many settings where universal screening is
not routinely done. Newborn hearing screening is completed
before hospital discharge, and infants who do not pass are
referred for repeated testing within the next 2 to 8 weeks. The
practice of universal hearing screening reduces the age at
which infants with hearing loss are identified and treated
(Joint Committee on Infant Hearing, 2000) (Fig. 19-9).
Collection of specimens. Ongoing evaluation of
a newborn often requires obtaining blood by the heel-stick
or venipuncture method or the collection of a urine specimen.
Heel stick. Most blood specimens are drawn by laboratory technicians. Nurses, however, may be required to perform heel sticks to obtain blood for glucose monitoring and
Fig. 19-9 Hearing screening in the newborn nursery.

(Courtesy Dee Lowdermilk, Chapel Hill, NC.)
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BOX 19-4
Standard Laboratory Values in the Neonatal Period

NEONATAL
1. HEMATOLOGIC VALUES
Clotting factors
Activated clotting time (ACT)
Bleeding time (Ivy)
Clot retraction
Fibrinogen
2 min
2 to 7 min
Complete 1 to 4 hr
125 to 300 mg/dl*
Hemoglobin (g/dl)
Hematocrit (%)
Reticulocytes (%)
Fetal hemoglobin (% of total)
Red blood cells (RBCs)/mcl
Platelet count/mm3
White blood cells (WBCs)/mcl
Neutrophils (%)
Eosinophils and basophils (%)
Lymphocytes (%)
Monocytes (%)
Immature WBCs (%)
TERM
PRETERM
14 to 24
44 to 64
0.4 to 6
40 to 70
4.8 106 to 7.1 106
150,000 to 300,000
9000 to 30,000
54 to 62
1 to 3
25 to 33
3 to 7
10
15 to 17
45 to 55
Up to 10
80 to 90
120,000 to 180,000
10,000 to 20,000
47
33
4
16
*dl refers to deciliter (1 dl 100 ml); this conforms to the SI system (standardized international measurements).
mcl refers to microliter.
NEONATAL
2. BIOCHEMICAL VALUES
Bilirubin, direct
Bilirubin, total
Cord:
Peripheral blood:
Blood gases
0 to 1 day
1 to 2 days
2 to 5 days
Arterial:
Venous:
Serum glucose
0 to 1 mg/dl
2 mg/dl
6 mg/dl
8 mg/dl
12 mg/dl
pH 7.31 to 7.49
PCO2 26 to 41 mm Hg
PO2 60 to 70 mm Hg
pH 7.31 to 7.41
PCO2 40 to 50 mm Hg
PO2 40 to 50 mm Hg
40 to 60 mg/dl
NEONATAL
3. URINALYSIS
Color
Specific gravity
pH
Protein
Glucose
Ketones
RBCs
WBCs
Casts
Clear, straw
1.001 to 1.020
5 to 7
Negative
Negative
Negative
0 to 2
0 to 4
None
Volume: 24 to 72 ml/kg excreted daily in the first few days; by week 1, 24-hr urine volume close to 200 ml.
Protein: may be present in first 2 to 4 days.
Osmolarity (mOsm/L): 100 to 600.
Some data from Hockenberry, M. (2003). Wongs nursing care of infants and children (7th ed.). St. Louis: Mosby; Pagana, K., & Pagana, T. (2003). Mosbys
diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby.
to measure hematocrit levels. The same technique is used to

obtain a blood sample for newborn genetic screening tests.
It may be helpful to warm the heel before the sample is
taken, because the application of heat for 5 to 10 minutes
helps dilate the vessels in the area. A cloth soaked with warm
water and wrapped loosely around the foot can effectively

warm the foot (Fig. 19-10, A). Disposable heel warmers also
are available from a variety of companies but should be used
with care to prevent burns. Nurses should wear gloves when
collecting any specimen. The nurse first cleanses the area
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CHAPTER
with alcohol, restrains the infants foot with his or her free
hand, and then punctures the site. A spring-loaded automatic
puncture device causes less pain and requires fewer punctures
than a manual lance blade.
The most serious complication of an infant heel stick is
necrotizing osteochondritis resulting from lancet penetration
of the bone. To prevent this, the stick should be made at the
outer aspect of the heel and should penetrate no deeper than
2.4 mm (Hockenberry, 2003). To identify the appropriate
puncture site, the nurse should draw an imaginary line from
between the fourth and fifth toes that runs parallel to the lateral aspect of the heel, where the stick should be made; a line
can also be drawn from the great toe that runs parallel to the
medial aspect of the heel, another site for a stick (Fig. 19-10,
B). Repeated trauma to the walking surface of the heel can
cause fibrosis and scarring that may lead to problems with
walking later in life.
19
After the specimen has been collected, pressure should

be applied with a dry gauze square, but no further alcohol
should be applied because this will cause the site to continue
to bleed. The site is then covered with an adhesive bandage.
The nurse ensures proper disposal of equipment used, reviews the laboratory slip for correct identification, and checks
the specimen for accurate labeling and routing.
A heel stick is traumatic for the infant and causes pain.
After several heel sticks, infants often withdraw their feet
when they are touched. To reassure the infant and promote
feelings of safety, the neonate should be cuddled and comforted when the procedure is complete and appropriate pain
management measures taken to minimize the pain.
Venipuncture. A venipuncture may be less painful
than a heel stick for blood sampling. Venous blood samples
can be drawn from antecubital, saphenous, superficial wrist,
and rarely, scalp veins. If an intravenous site is used to
Medial plantar nerve
B
Lateral plantar nerve
587
Medial plantar artery
Lateral plantar artery
Medial calcaneal nerves

Fig. 19-10 Heel stick. A, Newborn with foot wrapped for warmth to increase blood flow to extremity before heel stick. B, Heel-stick sites (shaded areas) on infants foot for obtaining samples
of capillary blood. (A, Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
588
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THE NEWBORN
obtain a blood specimen, it is important to consider the type

of infusion fluid, because mixing of the blood sample with
the fluid can alter the results.
When venipuncture is required, positioning of the needle is extremely important. Although regular venipuncture
needles may be used, some prefer butterfly needles. A

25-gauge needle is adequate for blood sampling in neonates,
with minimal hemolysis occurring when the proper procedure is followed. It is necessary to be very patient during the
procedure, because the blood return in small veins is slow,
Fig. 19-11 Application of mummy restraint. A, Infant is placed on folded corner of blanket.
B, One corner of blanket is brought across body and secured beneath the body. C, Second corner is brought across body and secured, and lower corner is folded and tucked or pinned in place.
D, Modified mummy restraint with chest uncovered. (From Hockenberry, M. [2003]. Wongs nursing care of infants and children [7th ed.]. St. Louis: Mosby.)
11/15/05
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CHAPTER
and consequently the small needle must remain in place

longer. The mummy restraint commonly is used to help secure the infant (Fig. 19-11).
For external jugular venipuncture, mummy the infant
as necessary, and then lower the infants head over a rolled
towel, the edge of a table, or your knee, and stabilize. For
femoral venipuncture, place your hands over the infants
knees, but avoid pressing your fingers over the inner aspect
of the thigh (Fig. 19-12, A). Both of these positions ensure
the safety of the infant and exposure of the puncture sites.
If the radial vein is used, the infants arm is exposed and held
securely in place.
If venipuncture or arterial puncture is being performed
for blood gas studies, crying, fear, and agitation will affect
the values; therefore every effort must be made to keep the
infant quiet during the procedure. For blood gas studies, the
blood sample tubes are packed in ice (to reduce blood cell
metabolism) and are taken immediately to the laboratory for
analysis.
Pressure must be maintained over an arterial or femoral
vein puncture with a dry gauze square for at least 3 to 5 min-
Fig. 19-12 A, Restraining infant for femoral vein puncture.

B, Modified side-lying position for lumbar puncture. (From
Hockenberry, M. [2003]. Wongs nursing care of infants and
children [7th ed.]. St. Louis: Mosby.)
19
589
utes to prevent bleeding from the site. For an hour after any
venipuncture, the nurse should then observe the infant frequently for evidence of bleeding or hematoma formation at
the puncture site. The infants tolerance of the procedure also
should be recorded. The infant should be cuddled and comforted when the procedure is completed.
Obtaining a urine specimen. Examination of urine
is a valuable laboratory tool for infant assessment; the way
in which the urine specimen is collected may influence the
results. The urine sample should be fresh and analyzed
within 1 hour of collection.
A variety of urine collection bags are available, including
the Hollister U-Bag (Fig. 19-13). These are clear plastic,
single-use bags with an adhesive material around the opening at the point of attachment.
To prepare the infant, the nurse removes the diaper and
places the infant in a supine position. The genitalia, perineum, and surrounding skin are washed and thoroughly
dried because the adhesive on the bag will not stick to moist,
powdered, or oily skin surfaces. The protective paper is removed to expose the adhesive (Fig. 19-13, A). In female infants, the perineum is first stretched to flatten skin folds, and
then the adhesive area on the bag is pressed firmly onto the
skin all around the urinary meatus and vagina. (NOTE: Start
with the narrow portion of the butterfly-shaped adhesive
patch.) Starting the application at the bridge of skin separating the rectum from the vagina and working upward is
most effective (Fig. 19-13, B). In male infants, the penis and
scrotum are tucked through the opening into the collection
bag before the protective paper is removed from the adhesive and it is pressed firmly onto the perineum, making sure
the entire adhesive is firmly attached to skin and the edges
of the opening do not pucker (Fig. 19-13, C). This helps ensure a leakproof seal and decreases the chance of contamination from stool. Cutting a slit in the diaper and pulling
the bag through the slit also may help prevent leaking.
The diaper is carefully replaced, and the bag is checked
frequently. When a sufficient amount of urine (this
amount varies according to the test done) appears, the bag
is removed. The infants skin is observed for signs of irritation while the bag is in place. The specimen can be aspirated
with a syringe or drained directly from the bag.
Collection of a 24-hour specimen can be a challenge; the
infant may need to be restrained. The 24-hour urine bag is
applied in the manner just described, and the urine is drained
into a receptacle. During the collection, the infants skin is
observed closely for signs of irritation and for lack of a proper
seal.
For some types of urine tests, urine can be aspirated directly from the diaper by means of a syringe without a needle. If the diaper has absorbent gelling material that traps
urine, a small gauze dressing or some cotton balls can be
placed inside the diaper and the urine aspirated from them
(Hockenberry, 2003).
Restraining the infant. Infants may need to be restrained to (1) protect the infant from injury, (2) facilitate
590
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THE NEWBORN
Fig. 19-13 Collection of urine specimen. A, Protective paper is removed from the adhesive surface. B, Applied to girls. C, Applied to boys. D, Cut to drain urine. E, Collection tube. (Permission
to use and/or reproduce this copyrighted material has been granted by the owner, Hollister, Inc.,
Libertyville, IL.)
examinations, and (3) limit discomfort during tests, procedures, and specimen collections (see Figs. 19-11 and 19-12).
The following special considerations must be kept in mind
when restraining an infant:
Apply restraints and check them to make sure they are
not irritating the skin or impairing circulation.
Maintain proper body alignment.
Apply restraints without using knots or pins if possible. If knots are necessary, make the kind that can be
released quickly. Use pins with care so that there is no
danger of their puncturing or pressing against the infants skin.
Check the infant hourly, or more frequently if indicated.
Restraint without appliance. The nurse may restrain
the infant by using the hands and body. Figure 19-12, B illustrates ways to restrain an infant in this manner.
Possible nursing diagnoses for the newborn from 2 hours
after birth until discharge include the following:
Ineffective breathing pattern related to

obstructed airway
Impaired gas exchange related to
ineffective breathing pattern
Ineffective thermoregulation related to
excess heat loss to the environment
Acute pain related to
circumcision
heel stick, venipuncture
Possible nursing diagnoses for the parents are as follows:
Readiness for enhanced family coping related to

knowledge of newborns social capabilities
knowledge of newborns dependency needs

knowledge of newborns biologic characteristics
Situational low self-esteem related to
misinterpretation of newborns behavioral cues
Examples of nursing diagnoses derived from specific assessment findings are listed in the Plan of Care.
Expected Outcomes of Care

The expected outcomes for newborn care relate to the infant
and parents. The outcomes for the infant are that the infant
will do the following:
Maintain an effective breathing pattern
Maintain effective thermoregulation
Remain free from infection
Establish adequate elimination patterns
Experience minimal pain
For the parents, expected outcomes include the following:
Attain knowledge, skill, and confidence relevant to infant care activities
State understanding of biologic and behavioral characteristics of their newborn
Have opportunities to intensify their relationship with
the infant
Begin to integrate the infant into the family
Plan of Care and Interventions

In the inpatient setting, priorities of care must be established
and a systematic teaching plan devised for infant care. One
way to accomplish this is to use critical path case management. A care path may be developed to cover the changes
expected in the infant during the first several days of life
(Care Path). When variations from the care path occur, further assessment and intervention may be necessary.
11/15/05
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CHAPTER
PLAN OF CARE
19
Normal Newborn
NURSING DIAGNOSIS Risk for ineffective airway

clearance related to excess mucus production or
improper positioning
Expected Outcomes Neonates airway remains
patent; breath sounds are clear, and no respiratory
distress is evident.
Nursing Interventions/Rationales
Teach parents that gagging, coughing, and sneezing are normal neonatal responses that assist the neonate in clearing
airways.
Teach parents feeding techniques that prevent overfeeding
and distention of the abdomen and to burp neonate frequently to prevent regurgitation and aspiration.
Position neonate on back when sleeping to prevent suffocation.
Suction mouth and nasopharynx with bulb syringe as
needed; clean nares of crusted secretions to clear airway and
prevent aspiration and airway obstruction.
NURSING DIAGNOSIS Risk for imbalanced body

temperature related to larger body surfaces in
relationship to mass
Expected Outcome Neonate temperature remains
in range of 36.5 C to 37.2 C.
Maintain neutral thermal environment to identify any

changes in neonates temperature that may be related to
other causes.
Monitor neonates axillary temperature frequently to identify
any changes promptly and ensure early interventions.
Bathe neonate efficiently when temperature is stable, using
warm water, drying carefully, and avoiding exposing neonate
to drafts to avoid heat losses from evaporation and convection.
Report any alterations in temperature findings promptly to
assess and treat for possible infection.
NURSING DIAGNOSIS Risk for infection related

to immature immunologic defenses and environmental exposure
Expected Outcome The neonate will be free from
signs of infection.
Review maternal record for evidence of any risk factors to ascertain whether the neonate may be predisposed to infection.
Monitor vital signs to identify early possible evidence of infection, especially temperature instability.
Have all care providers, including parents, practice good
handwashing techniques before handling newborn to prevent spread of infection.
Protective environment
The provision of a protective environment is basic to the
care of the newborn. The construction, maintenance, and
operation of nurseries in accredited hospitals are monitored
by national professional organizations such as the AAP, Joint
Commission on Accreditation of Healthcare Organizations,
Occupational Health and Safety Administration, and local
or state governing bodies. In addition, hospital personnel develop their own policies and procedures for protecting the
Monitor environment for hazards such as sharp objects, long

fingernails of caretaker and neonate, and jewelry of caretaker
that may be sharp to prevent injury.
Handle neonate gently and support head, ensure use of car
seat by parents, teach parents never to place neonate on high
surface unsupervised, and to supervise pet and sibling interactions to prevent injury.
Assess neonate frequently for any evidence of jaundice to
identify rising bilirubin levels, treat promptly, and prevent kernicterus.
NURSING DIAGNOSIS Readiness for enhanced

family coping related to anticipatory guidance
regarding responses to neonates crying
Expected Outcome Parents will verbalize understanding of methods of coping with neonates crying and describe increased success in interpreting
neonates cries.
Provide prescribed eye prophylaxis to prevent infection.

Keep genital area clean and dry using proper cleansing techniques to prevent skin irritation, cross-contamination, and infection.
Keep umbilical stump clean and dry and keep exposed to air
to allow to dry and minimize chance of infection.
If infant is circumcised, keep site clean and apply diaper
loosely to prevent trauma and infection.
Teach parents to keep neonate away from crowds and
environmental irritants to reduce potential sources of infection.
NURSING DIAGNOSIS Risk for injury related to

sole dependence on caregiver
Expected Outcome Neonate remains free of injury.
591
Alert parents to crying as neonates form of communication

and that cries can be differentiated to indicate hunger, wetness, pain, and loneliness to provide reassurance that crying is not indicative of neonates rejection of parents and
that parents will learn to interpret the different cries of their
child.
Differentiate self-consoling behaviors from fussing or crying
to give parents concrete examples of interventions.
Discuss methods of consoling a neonate who has been crying, such as checking and changing diapers, talking softly to
neonate, holding neonates arms close to body, swaddling,
picking neonate up, rocking, using a pacifier, feeding, or burping to provide anticipatory guidance.
newborns under their care. Prescribed standards cover areas

such as the following:
Environmental factors: Provision of adequate lighting,
elimination of potential fire hazards, safety of electrical
appliances, adequate ventilation, and controlled temperature (i.e., warm and free of drafts) and humidity
(lower than 50%).
Measures to control infection: Adequate floor space
to permit the positioning of bassinets at least 3 feet
Text continued on p. 595
CD: Plan of CareNormal Newborn
Feeding
Breast
Initiatedlatch-on
30-50
breaths/min
1 latch-on
30-50
breaths/min
Blood pressure on
admission per
protocol (not
usual unless indicated)
100-180 beats/min 80-180 beats/min 120-140
beats/min
Respiratory 30-50 breaths/min

rate
(may be less if
asleep)
Heart rate
Vital signs
36.5 - 37.2 C
36.5 - 37.2 C
1 latch-on
30-50 breaths/min
2 latch-ons verified
120-140 beats/min VS stable
36.5 - 37.2 C
24 HR
3-4 successful
latch-ons verified
30-50 breaths/min
VS stable: 120140 beats/min
36.5 - 37.2 C
ID band on
ID band on
Bulb syringe in
Bulb syringe in
crib; NB alarm
crib; NB alarm
system active
system active
18 HR
36-48 HR TO DISCHARGE
Feeding successfully 8-10

times/day; discuss and reinforce
feeding cues and associated behaviors
VS stable and documented

If murmur present, document
Monitor blood pressure per
protocol
36.5 - 37.2 C
Reinforce teaching for taking
axillary temperature and when
to take
Thermometer type
Normal ranges
Discuss home environment temperature
ID band on
Remove at discharge only
Parents verbalize appropriate car
seat in place
Discuss and reinforce home safety,
including abduction prevention,
infection prevention, car seat
safety, and falls prevention
Reinforce teaching for use of bulb
syringe
Discuss sleep positionon back,
always; sleep environment (mattress, crib rails)
Reinforce smoke-free environment
around infant
Deactivate NB alarm system at discharge
11:09 AM
36.5 - 37.2 C
ID band on
ID band on
Bulb syringe in Bulb syringe in
crib; NB alarm
crib; NB alarm
system active
system active
12 HR
6 HR
2-3 HR
ID band on
Parent teaching
regarding
bulb syringe;
NB alarm system active
FIRST HOUR
ID band on and
verified matching parents;
bulb syringe
(for suction) at
bedside; newborn safety
alarm system
activated.*
UNIT SIX
11/15/05
Tempera36.5 - 37.2 C
ture (axillary)
Safety
Healthy Term Newborn
592
CARE
ASPECTS
C A R E PAT H
Page 592
THE NEWBORN
5-6 mg/dl
Clamped; no
drainage
Continued evaluation for absence

of bleeding and presence of
voiding
Dressing applied with each diaper
change depending on method
(Gomco and Mogen clamp)
Ring intact if PlastiBell
Reinforce teaching on care of circumcision at home; pain management care
Cord drying; care reinforced to parents; clamp removed before discharge
5-6 mg/dl; color Note skin color; transcutaneous

jaundice meter reading per propink; note if
tocol AND check serum bilirubin
jaundice presat 24-36 hr:
ent and docu7 mg/dllow risk
mented; tran7 mg/dllow intermediate risk
scutaneous
11-13 mg/dlhigh intermedibilirubin check
ate risk
per protocol
13 mg/dlhigh risk
Pain managePain managementrecommentrecommend topical

mend topical
anesthesia
anesthesia with
with DPNB or
DPNB or reregional and
gional and oral
oral sucrose;
sucrose; verify
verify after
after procedure
procedure
Cord drying; no
drainage
Demonstrates interest in newborn

care; participates in newborn
care; asks appropriate questions
regarding home care; follow-up
time and location provided
19
Bilirubin
Cord care per

institutional
protocol
Continued involvement in
newborn care
CHAPTER
5-6 mg/dl
Cord clamped
Cord care
2-3 voids minimum; or number of

voids-number of days old
Reinforce teaching and careminimum of 5 6 voids/day
1 meconium doc- 1 meconium documented

umented
Reinforce teaching and careapproximately 1-2 stools/72-96 hr
after first week of life depending
on feeding method; more if
breastfeeding
Minimum of 3
voids/24 hr in
first few days
4-5 feedings veri- Feeding successfully 5-6 times/day;

fied; adequate
discuss and reinforce feeding
suck, swallow,
cues and associated behaviors
and breathing
coordination
11:01 AM
Circumcision
Initiated eye contact and verbalization
Parent interaction
Check for stool
3 successful
feedings verified15-30
ml each
11/30/05
Ongoing contact Exhibit newborn Involvement in

care interest
newborn
and involvecare
ment
Verify anal patency Check for stool
Stooling
Check
Elimination
Voiding
1 void
Sips to verify
Sips to verify
2 feedings
suck, swallow,
suck, swallow,
15-25 ml each
and breathing
and breathing
Formula
Page 593
593
May be drowsy
but arousable
Activity
Active and alert

Sleep periods
noted
Reflexes present
Neurologic status intact
18 HR
Prepared by David Wilson, MS, RNC.

DPNB, Dorsal penile nerve block; HBsAg, hepatitis B surface antigen; ID, identification; PKU, phenylketonuria; VS, vital signs.
*NB alarm system is the hospital protocol designed to protect infant from abduction.
If still in hospital.
Minimum observed and documented.
Hearing screening
completed and
documented
No visible jaundice; pink
12 HR
36-48 HR TO DISCHARGE
Discuss and reinforce sleep-wake

patterns with parents; reinforce
cues to active engagement with
infant (eye contact, socialization); potential signs of danger
(decreased activity; not arousable for feedings; color changes
[not acrocyanosis], central
cyanosis, apnea)
Check eye status; Reinforce hepatitis B vaccination at

verify free of
follow-up if not given in birth
drainage
hospital
Note colordocument
Provide parent instruction regarding jaundice and follow-up visit
with primary care practitioner
within 3-4 days
Newborn screen- Verify newborn screening completed, including PKU after 24 hr
ing completed
after 24 hr
of oral intakereschedule if
document time
needed
and method
Check for jaundice
24 HR
11:09 AM
Active and alert

Flexed, strong
suck reflex
Eye prophylaxis Hepatitis B vacVitamin K

cine within 12
Maternal HBsAg
hr of birth if
status verified
mother posiand docutive; documented
ment
6 HR
11/15/05
Medications
Active, flexed,
primitive reflexes present
(Moro, suck,
tonic neck,
Babinski)
Bilirubin
contd
2-3 HR
UNIT SIX
Newborn
screening
FIRST HOUR
Healthy Term Newborncontd
594
CARE
ASPECTS
C A R E PAT H
Page 594
THE NEWBORN
11/15/05
11:09 AM
Page 595
CHAPTER
19
595
apart in all directions, handwashing facilities, and areas for cleaning and storing equipment and supplies.
Only those personnel directly involved in the care of
mothers and infants are allowed in these areas, thereby reducing the opportunities for the transmission of pathogenic
organisms.
NURSE ALERT Personnel are instructed to use good
handwashing techniques. Handwashing between each
infant handling is the single most important measure
in the prevention of neonatal infection.
Health care personnel must wear gloves when handling

the infant until blood and amniotic fluid have been removed
from the infants skin, when drawing blood (e.g., heel stick),
when caring for a fresh wound (e.g., circumcision), and during diaper changes.
Visitors and health care providers such as nurses, physicians, parents, brothers and sisters, department supervisors,
electricians, and housekeepers are expected to wash their
hands before having contact with infants or equipment.
Cover gowns are not necessary.
Individuals with infectious conditions are excluded from
contact with newborns or must take special precautions
when working with infants. This includes persons with upper respiratory tract infections, gastrointestinal tract infections, and infectious skin conditions. Most agencies have
now coupled this day-to-day self-screening of personnel with
yearly health examinations.
Safety factors: Health care institutions must be proactive in protecting newborns from abductions. Examples of the measures include placing identification
bracelets on infants and their parents, using identification bands with radiofrequency transmitters that set
off an alarm if the bracelet is removed or if a certain
threshold is crossed (doorway to exit unit or building),
and footprinting or taking identification pictures immediately after birth, before the infant leaves the
Fig. 19-14 Neonatal safety device. (Courtesy Shannon

Perry, Phoenix, AZ.)
Fig. 19-15 Photo ID for personnel working in maternity

settings. (Courtesy Shannon Perry, Phoenix, AZ.)
mothers side (Fig. 19-14). Personnel wear picture identification badges or other badges that identify them as
newborn unit personnel (Fig. 19-15). Mother-baby
units may have infant tracking systems that will set off
an alarm if a baby is left alone or is with unauthorized
personnel. Mothers are instructed to be certain they
know the identity of anyone who cares for the infant
and never to release the infant to anyone who is not
wearing the appropriate identification.
Supporting parents in the care of
their infant
The sensitivity of the caregiver to the social responses of
the infant is basic to the development of a mutually satisfying parent-child relationship. Sensitivity increases over time
as parents become more aware of their infants social capabilities (Cultural Considerations box).
Social interaction. The activities of daily care during the neonatal period are the best times for infant and family interactions. While caring for their baby, the mother and
father can talk to the infant, play baby games, caress and cuddle the child, and perhaps use infant massage. Too much
stimulation should be avoided after feeding and before a
sleep period. Older childrens contact with a newborn is encouraged and supervised based on the developmental level
of the child (Fig. 19-16).
Infant feeding. The infant is put to breast as soon
as possible after birth or at least within 4 hours. If the infant
is to be bottle-fed, a nurse may first offer a few sips of sterile water to make certain the sucking and swallowing reflexes
are intact and that there are no anomalies such as a tracheoesophageal fistula. Most infants are on demand feeding
schedules and are allowed to feed when they awaken. Ordinarily mothers are encouraged to feed their infants every
3 to 4 hours during the day and only when the infant awakens during the night in the first few days after birth. Formulafed infants usually eat approximately every 3 to 4 hours.
596
UNIT SIX
11/30/05
11:01 AM
Page 596
THE NEWBORN
Medication Guide
Hepatitis B Vaccine (Recombivax HB,
Engerix-B)
ACTION
Hepatitis B vaccine induces protective antihepatitis B

antibodies in 95% to 99% of healthy infants who receive
the recommended three doses. The duration of protection of the vaccine is unknown.
INDICATION
Hepatitis B vaccine is for immunization against infection caused by all known subtypes of hepatitis B virus
(HBV).
NEONATAL DOSAGE
Fig. 19-16 Mother supervising contact of older sibling

with newborn. (Courtesy Rebekah Vogel, Fort Collins, CO.)
Breastfed babies nurse more often (every 2 to 3 hours) than

bottle-fed babies because breast milk is digested faster than
formulas made from cows milk, and the stomach empties
sooner as a result. Water supplements are not recommended.
For a thorough discussion of infant feeding, see Chapter 20.
Therapeutic and surgical
procedures
Intramuscular injection. As discussed previously, it is routine to administer a single dose of 0.5 to 1 mg
of vitamin K intramuscularly to an infant soon after birth
(see Medication Guide box on p. 579).
Hepatitis B (Hep B) vaccination is recommended for all infants. Infants at highest risk for contracting hepatitis B are
those born to women who come from Asia, Africa, South
America, the South Pacific, or southern or eastern Europe
(Medication Guide). If the infant is born to an infected mother
or to a mother who is a chronic carrier, hepatitis vaccine and
hepatitis B immune globulin (HBIG) should be administered
within 12 hours of birth (Medication Guide). The hepatitis
Cultural Considerations
Cultural Beliefs and Practices
Nurses working with childbearing families from other cultures and ethnic groups must be aware of cultural beliefs
and practices that are important to individual families.
People with a strong sense of heritage may hold on to traditional health beliefs long after adopting other U.S.
lifestyle practices. These health beliefs may involve practices regarding the newborn. For example, some Asians,
Hispanics, eastern Europeans, and Native Americans delay breastfeeding because they believe that colostrum is
bad. Some Hispanics and African-Americans place a
belly band over the infants navel. The birth of a male child
is generally preferred by Asians and Indians, and some
Asians and Haitians delay naming their infants (DAvanzo
& Geissler, 2003).
The usual dosage is Recombivax HB, 5 mg/0.5 ml, or

Engerix-B, 10 mg/0.5 ml, at 0, 1, and 6 mo. An alternate
dosing schedule is 0, 1, 2, and 12 mo and is usually for
newborns whose mothers were hepatitis B surface
antigen (HBsAg)positive.
ADVERSE REACTIONS
Common adverse reactions are rash, fever, erythema,

swelling, and pain at injection site.
Parental consent must be obtained before administration. Wear gloves. Administer in the middle third of
the vastus lateralis muscle by using a 25-gauge, 5 8inch needle. Inject into skin that has been cleaned, or
allow alcohol 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. Insert the needle at a 90-degree angle; 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. If the infant was
born to HBsAg-positive mother, hepatitis B immune
globulin (HBIG) should be given within 12 hr of birth
in addition to the HB vaccine. Separate sites must be
used.
vaccine is given in one site and the HBIG in another. For infants born to healthy women, the first dose of the vaccine may
be given at birth or at age 1 or 2 months. Parental consent
should be obtained before these vaccines are administered.
In most cases, a 25-gauge, 5 8-inch needle should be used
for the vitamin K and hepatitis vaccine injections. A
22-gauge needle may be necessary if thicker medications such
as some penicillins are to be given.
Selection of the site for injection is important. Injections
must be given in muscles large enough to accommodate the
medication, and major nerves and blood vessels must be
avoided. The muscles of newborns may not tolerate more
than a 0.5 ml per intramuscular injection. The injection site
for newborns is the vastus lateralis (Fig. 19-17). The dorsogluteal muscle is very small, poorly developed, and dangerously close to the sciatic nerve, which occupies a larger
area in infants compared with older children. Therefore it
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19
597
Medication Guide
Hepatitis B Immune Globulin
ACTION
Hepatitis B immune globulin (HBIG) provides a high

titer of antibody to hepatitis B surface antigen (HBsAg).
Femoral
artery
Greater
trochanter
Femoral
vein
INDICATION
The HBIG vaccine provides prophylaxis against infection in infants born of HBsAg-positive mothers.
Rectus
femoris
muscle
NEONATAL DOSAGE
Administer one 0.5-ml dose intramuscularly within

12 hr of birth.
Vastus
lateralis
muscle
ADVERSE REACTIONS
Hypersensitivity may occur.
Must be given within 12 hr of birth. Wear gloves. Administer in the middle third of the vastus lateralis muscle by using a 25-gauge, 5 8-inch needle. Inject into skin
that has been cleaned, or allow alcohol 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. Insert 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. May be given at same time as hepatitis B
vaccine but at a different site.
Patella
B
is not recommended that it be used as an injection site until the child has been walking for at least 1 year. The newborns deltoid muscle has an inadequate amount of muscle
for intramuscular injection.
The neonates leg should be stabilized. Gloves should be
worn by the person giving the injection. The nurse cleanses
the injection site with an appropriate skin antiseptic (e.g., alcohol), then pinches up the infants muscle between the
thumb and forefinger. The needle is inserted into the vastus lateralis at a 90-degree angle. The muscle is released and
the plunger of the syringe gently withdrawn. If no blood is
aspirated, the medication is injected. If blood is aspirated,
the needle is withdrawn and the injection is given in another
site. After the injection has been given, the needle is withdrawn quickly and the site massaged with a gauze square to
hasten absorption, unless contraindicated. A small amount
of bleeding at the injection site is not uncommon, but it is
not necessary to cover the site with an adhesive bandage.
Pressure should be applied until bleeding stops.
The nurse should always remember to comfort the infant
after an injection and to discard equipment properly. It is
important to record the name of the medication, date and
time of administration, amount, route, and site of injection
on the newborns chart.
Therapy for hyperbilirubinemia. The best
therapy for hyperbilirubinemia is prevention. Because bilirubin is excreted primarily through stooling, prevention can
Fig. 19-17 Intramuscular injection. A, Acceptable intramuscular injection site for newborn infant. X, Injection site. B,
Infants leg stabilized for intramuscular injection. Nurse is
wearing gloves to give injection. (B, Courtesy Marjorie Pyle,
RNC, Lifecircle, Costa Mesa, CA.)
be facilitated by early feeding, which stimulates the passage

of meconium. However, despite early passage of meconium,
the term infant may have trouble conjugating the increased
amount of bilirubin derived from disintegrating fetal red
blood cells. As a result, the serum levels of unconjugated
bilirubin may increase beyond normal limits, causing hyperbilirubinemia (see Chapter 18). The goal of treatment of
hyperbilirubinemia is to help reduce the newborns serum
levels of unconjugated bilirubin. The two principal ways of
doing this are phototherapy and, rarely, exchange blood
transfusion. Exchange transfusion treats those infants
whose increased levels of bilirubin cannot be controlled by
phototherapy (Ip et al., 2004).
Phototherapy. During phototherapy the unclothed
infant is placed beneath a bank of lights. The distance may
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vary based on unit protocol and the type of light used. There
should always be a Plexiglas panel or shield between the
lights and the infant when conventional lighting is used. The
most effective therapy is achieved with lights at 400 to 500
manometers, and blue light spectrum is the most efficient.
The lamp energy should be monitored routinely during treatment with a photometer to ensure efficacy of therapy. Phototherapy is carried out until the infants serum bilirubin
level decreases to within an acceptable range. The decision
to discontinue therapy is based on the observation of a definite downward trend in the bilirubin values. After therapy
has been terminated, the infant may have a rebound in
bilirubin levels, which is usually harmless (Kliegman, 2002).
Several precautions must be taken while the infant is undergoing phototherapy. The infants eyes must be protected
by an opaque mask to prevent overexposure to the light. The
eye shield should cover the eyes completely but not occlude
the nares. Before the mask is applied, the infants eyes should
be closed gently to prevent excoriation of the corneas. The
mask should be removed during infant feedings so that the
eyes can be checked and the parents can have visual contact
with the infant (Fig. 19-18).
To promote optimal skin exposure during phototherapy,
the diaper may be left off, or a string bikini made from a
disposable face mask may be used to cover the infants gen-
Fig. 19-18 A mother can breastfeed her baby without interrupting phototherapy. Eye patches are worn when infant is
under bililights but not when a BiliBlanket is used. (Courtesy
Respironics, Inc., Pittsburgh, PA.)
ital area. Before placing the mask on the infant, the metal
strip must be removed from the face mask to prevent burning the infant. Lotions and ointments should not be used
during phototherapy because they absorb heat, and this can
cause burns.
Phototherapy may cause changes in the infants temperature depending partially on the bed used: bassinet, isolette,
or radiant warmer. The infants temperature is closely monitored. Phototherapy lights may increase insensible water
loss, placing the infant at risk for fluid loss and dehydration;
therefore it is important that the infant be adequately hydrated. Hydration maintenance in the healthy newborn is
accomplished with human milk or infant formula; there is
no reason to administer glucose water or plain water because
these do not promote excretion of bilirubin in the stools and
may actually perpetuate enterohepatic circulation, thus
delaying bilirubin excretion. Urine output may be decreased
or unaltered; the urine may have a brown or gold appearance. All aspects of the phototherapy treatment should be
accurately recorded in the infants chart.
The number and consistency of stools are monitored.
Bilirubin breakdown increases gastric motility, which results
in the formation of loose stools that can cause skin excoriation and breakdown. The infants buttocks are cleaned after each stool to help maintain skin integrity. A fine maculopapular rash may appear during phototherapy, but this is
transient. Because visualization of the infants skin color is
difficult with blue light, appropriate cardiorespiratory monitoring should be implemented based on the infants overall condition.
An alternative device for phototherapy that is safe and effective is a fiberoptic panel attached to an illuminator. This
fiberoptic blanket may be wrapped around the newborns
torso or flat in the bed, thus delivering continuous phototherapy. Although the fiberoptic lights do not produce
heat as do conventional lights, staff should ensure that there
is a covering pad between the infants skin and the fiberoptic device. This helps to prevent burns, especially in preterm
infants. During treatment with the fiberoptic blanket the
newborn can remain in the mothers room in an open crib
or in her arms (Fig. 19-18, C); follow unit protocol for the
use of eye patches. The blanket also may be used for home
care. In certain instances the infants bilirubin levels may be
increasing rapidly and intensive phototherapy is required;
this involves the use of a combination of conventional lights
and fiberoptic blankets.
Exchange transfusion. Exchange transfusion is usually reserved for infants at risk for kernicterus because of high
bilirubin levels. Small amounts of cross-matched whole
blood are transfused into the infant as equivalent amounts
of the infants blood are withdrawn and discarded. This is
most often accomplished through an umbilical venous
catheter. Potential complications of exchange transfusion include transfusion reaction, infection, metabolic instability,
and complications related to placement of the umbilical
catheter (Kliegman, 2002) (see Chapter 27).
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Parent education. Serum levels of bilirubin in the

newborn continue to increase until the fifth day of life.
Many parents leave the hospital within 24 hours, and some
as early as 6 hours after birth. Therefore parents must be able
to assess the newborns degree of jaundice. They should have
written instructions for assessing the infants condition and
the name of the contact person to whom to report their findings and concerns. Some health care agencies have a nurse
make a home visit to evaluate the infants condition. If it
proves necessary to measure the infants bilirubin levels after discharge from the hospital, either the home care nurse
may draw the blood specimen or the parents may take the
baby to a laboratory for the determination.
Home phototherapy. Healthy term infants may at
times be discharged home and need phototherapy for hyperbilirubinemia. Candidates for home phototherapy include those infants who are healthy and active with no signs
and symptoms of other complications; the parents or other
caregivers must be willing and able to assume responsibility for therapy maintenance and monitoring, and the home
environment should be adequate with a telephone, heat, and
electricity (University of California San Francisco Home
Health Care [UCSF], 2001). Home health care nurses are
usually responsible for assessing the parents or other caregivers willingness to use the equipment and monitor the infant and making home visits to assess the infants response
to therapy, including obtaining blood specimens for measuring bilirubin levels. The company that provides the home
therapy equipment is responsible for setting up the phototherapy unit and teaching the parents or caregivers how
to use the equipment. The home care nurse schedules home
visits to assess the infants response to therapy including
weight, feeding, output, and temperature stability. Additional
education of parents may be necessary; their understanding
of the therapy and their responsibilities is assessed. Blood
may be drawn for laboratory work, and results reported to
the primary health care provider. When therapy is discontinued, follow-up visits for monitoring may be ordered. The
equipment company is called to arrange for pick-up of the
phototherapy unit (UCSF Home Health Care, 2001).
Circumcision. Circumcision of newborn males is
commonly performed in the United States, although there
is controversy over its value. The AAP Task Force on Circumcision (1999) noted that, although there is scientific evidence of potential medical benefits of circumcision, the data
are not sufficient to recommend routine circumcision. The
Task Force further recommended that if circumcision is performed, analgesia should be used. ACOG (2001) and the
American Medical Association (2005) have issued similar recommendations regarding newborn circumcision.
Circumcision is a matter of personal parental choice. Parents usually decide to have their newborn circumcised for
one or more of the following reasons: hygiene, religious conviction, tradition, culture, or social norms. Regardless of the
reason for the decision, parents should be given unbiased information and the opportunity to discuss the benefits and
19
599
risks of the procedure. Suggested medical benefits of circumcision for the infant include decreased incidence of urinary tract infection and decreased risk for sexually transmitted infection, penile cancer, and human papilloma virus
(HPV) infection. There may be a lower risk of cervical cancer among female partners of circumcised men (Alanis &
Lucidi, 2004). Although there may be potential benefits,
none of these are deemed sufficient to suggest that newborn
males be routinely circumcised (AAP Task Force on Circumcision, 1999). Risks and potential complications associated with circumcision include hemorrhage, infection, and
penile injury (removal of excessive skin, damage to the meatus or glans) (Alanis & Lucidi, 2004).
Expectant parents should begin learning about circumcision during the prenatal period, but circumcision often is
not discussed with the parents before labor. In many instances, it is only when the mother is being admitted to the
hospital or birth unit that parents are first confronted with
the decision regarding circumcision. Because the stress of the
intrapartal period makes this a difficult time for parental decision making, this is not an ideal time to broach the topic
of circumcision and expect a well-thought-out decision.
Procedure. Circumcision involves removing the prepuce (foreskin) of the glans. The procedure is usually not
done immediately after birth because of the danger of cold
stress but is performed in the hospital before the infants discharge. The circumcision of a Jewish male is commonly performed on the eighth day after birth and is done at home,
in a ceremony called a bris. This timing is logical from a physiologic standpoint because clotting factors decrease somewhat immediately after birth and do not return to prebirth
levels until the end of the first week.
Formula feedings are usually withheld up to 4 hours before the circumcision to prevent vomiting and aspiration;
breastfed infants may be allowed to nurse up until the procedure is done; this varies with unit protocol. To prepare the
infant for the circumcision, he is positioned on a plastic
restraint form (Fig. 19-19), and his penis is cleansed with soap
and water or a preparatory solution such as povidone-iodine.
The infant is draped to provide warmth and a sterile field,
and the sterile equipment is readied for use.
Although some circumcision procedures require no special equipment or appliances (Fig. 19-20), numerous instruments have been designed for this purpose. Use of the
Gomco, Yellen, or Mogen clamp (Fig. 19-21) may make this
an almost bloodless operation. The procedure itself takes
only a few minutes. After it is completed, a small petrolatum gauze dressing or a generous amount of petrolatum may
be applied for the first day or two to prevent the diaper from
adhering to the site. A PlastiBell also may be used for the circumcision. The advantages to its use are that it applies constant direct pressure to prevent hemorrhage during the procedure and afterward protects against infection, keeps the site
from sticking to the diaper, and prevents pain with urination.
To use the bell for circumcision, first fit it over the glans, tie
the suture around the rim of the bell, and then cut away
CD: Critical Thinking ExerciseCircumcision
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THE NEWBORN
Suture
Cone
A
Prepuce
Fig. 19-19 Proper positioning of infant in Circumstraint.

(Photo by Paul Vincent Kuntz, Texas Childrens Hospital, Houston, TX.)
excess prepuce. The plastic rim remains in place for about

a week until it falls off, after healing has taken place (Fig.
19-22). Petrolatum need not be applied when the PlastiBell
is used (Glass, 2005).
Discomfort. Circumcision is painful, and the pain is
manifested by both physiologic and behavioral changes in
Fig. 19-20 Technique of circumcision. A to D, Prepuce is

stripped and slit to facilitate its retraction behind glans penis.
E, Prepuce is clamped and excessive prepuce cut off. F and G,
A very small needle and plain 2-0 or 3-0 catgut are used for
suture material; some physicians prefer silk.
Fig. 19-21 Circumcision with Yellen clamp. A, Prepuce

drawn over cone. B, Yellen clamp is applied, hemostasis occurs, and then prepuce (over cone) is cut away.
the infant. The AAP Task Force on Circumcision (1999) recommends the use of environmental, nonpharmacologic, and
pharmacologic pain interventions to prevent, decrease, or alleviate pain during neonatal circumcision.
Three types of anesthesia and analgesia are used in newborns who undergo circumcisions. These include (from most
effective to less effective) ring block, dorsal penile nerve block
(DPNB), and topical anesthetic (AAP Task Force on Circumcision, 1999). Nonpharmacologic methods such as nonnutritive sucking, containment, and swaddling may be used
in addition to pharmacologic use of oral acetaminophen and
a concentrated oral glucose solution. A combination of ring
block or DPNB, topical anesthetic, nonnutritive sucking,
oral acetaminophen, concentrated oral sucrose solution
(2 ml of a 24% concentration given during the procedure on
a pacifier, with a syringe or nipple), and swaddling has been
shown to be the most effective at decreasing the pain associated with circumcision.
A ring block is the injection of buffered lidocaine administered subcutaneously on each side of the penile shaft.
A DPNB includes subcutaneous injections of buffered lidocaine at the 2 oclock and 10 oclock positions at the base
of the penis. The circumcision should not be done for at
least 5 minutes after these injections.
A topical cream containing prilocaine-lidocaine such as
EMLA can be applied to the base of the penis at least 1 hour
before the circumcision. The area where the prepuce attaches
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Fig. 19-22 Circumcision by using Hollister PlastiBell. A,

Suture around rim of PlastiBell controls bleeding. B, Plastic rim
and suture drop off in 7 to 10 days. (Permission to use and/or
reproduce this copyrighted material has been granted by the
owner, Hollister, Inc., Libertyville, IL.)
to the glans is well coated with 1 g of the cream and then

covered with a transparent occlusive dressing or finger cot.
Just before the procedure, the cream is removed. Blanching
or redness of the skin may occur (Taddio, Ohlsson, &
Ohlsson, 2001).
After the circumcision, the infant is comforted until he
is quieted. If the parents were not present during the procedure, the infant is returned to them. The infant may be
fussy for several hours, or he may be sleepy and difficult to
awaken for feedings. Oral acetaminophen may be administered after the procedure every 4 hours (as ordered by the
practitioner) for a maximum of five doses in 24 hours or a
maximum of 75 mg/kg/day (Alanis & Lucidi, 2004).
Nurses are instrumental in implementing changes in
health care practices to effectively manage the pain of neonatal circumcision (Razmus, Dalton, & Wilson, 2004).
Care of the newly circumcised infant. Bleeding is
the most common complication of circumcision (AAP Task
19
601
Force on Circumcision, 1999). The nurse checks the infant

hourly for the 12 hours after the procedure to make sure no
bleeding is occurring and that voiding is normal. If bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a folded sterile gauze
square; absorbable gelatin sponge (Gelfoam) powder or
sponge may be applied to stop bleeding. If bleeding is not
easily controlled, a blood vessel may require ligation. In this
event, one nurse notifies the physician and prepares the necessary equipment (circumcision tray and suture material),
while another nurse maintains intermittent pressure until the
physician arrives. If the parents take the baby home before
the end of the 12-hour observation period, they must be instructed about postcircumcision care and when to notify the
physician (Teaching Guidelines box). Before the infant is discharged, the nurse checks to see that the parents have the
physicians telephone number.
If the PlastiBell technique was used, the parents are instructed to observe the position of the plastic ring on the
glans; it should remain on the glans (not on the shaft of the
penis) and should fall off within 5 to 7 days. No petrolatum
is used in caring for the penis circumcised with the PlastiBell
technique. Otherwise, care is the same as for the other types
of circumcision.
Neonatal pain
Until recent years, pain in the neonate was unrecognized
and untreated. A common myth was that because newborns
are developmentally immature, they do not experience pain,
nor do they recall having felt pain. Fortunately, care
providers now acknowledge that newborns actually do feel
pain. Much attention has been drawn to assessment of that
pain as well as to interventions that alleviate discomfort and
return the newborn to a state of equilibrium (Clifford,
Stringer, Christensen, & Mountain, 2004).
Pain has physiologic and psychologic components. The
psychologic component of pain and the diffuse total body
response to pain exhibited by the neonate led many health
care providers to believe that infants, especially preterm infants, do not experience pain. The central nervous system
is well developed, however, as early as 24 weeks of gestation.
The peripheral and spinal structures that transmit pain information are present and functional between the first and
second trimester. The pituitary-adrenal axis also is well developed at this time, and a fight-or-flight reaction is observed
in response to the catecholamines released in response to
stress (AAP & Canadian Paediatric Society, 2000; Walden &
Franck, 2003).
The physiologic response to pain in neonates can be life
threatening. Pain response can decrease tidal volume, increase demands on the cardiovascular system, increase
metabolism, and cause neuroendocrine imbalance. The
hormonal-metabolic response to pain in a term infant has
greater magnitude and shorter duration than that in adults.
The newborns sympathetic response to pain is less mature
and therefore less predictable than an adults.
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TEACHING GUIDELINES
Care of the Circumcised Newborn at Home
Wash hands before touching the newly circumcised penis.
CHECK FOR BLEEDING
Check circumcision for bleeding with each diaper

change.
If bleeding occurs, apply gentle pressure with a folded
sterile gauze square. If bleeding does not stop with pressure, notify primary health care provider.
CHECK FOR INFECTION
OBSERVE FOR URINATION
Check to see that the infant urinates after being circumcised.

Infant should have a wet diaper 6 to 10 times per
24 hours.
feces. Apply petrolatum to the glans with each diaper

change (omit petrolatum if PlastiBell was used).
Use soap only after circumcision is healed (5 to 6 days).
Fanfold diaper to prevent pressure on the circumcised
area.
Glans penis is dark red after circumcision, then becomes

covered with yellow exudate in 24 hours. This is normal
and will persist for 2 to 3 days. Do not attempt to remove
it.
Redness, swelling, or discharge indicates infection. Notify primary health care provider if you think the circumcision area is infected.
KEEP AREA CLEAN
PROVIDE COMFORT
Change diaper and inspect circumcision at least every

4 hours.
Wash penis gently with warm water to remove urine and
Assessment. Pain can be assessed in behavioral,

physiologic or autonomic, and metabolic categories
(Walden & Franck, 2003).
Behavioral responses. The most common behavioral
sign of pain is a vocalization or crying, ranging from a whimper to a distinctive high-pitched, shrill cry. Facial expressions
of pain include grimacing, eye squeeze, brow contraction,
deepened nasolabial furrows, a taut and quivering tongue, and
open mouth. The infant will flex and adduct the upper body
and lower limbs in an attempt to withdraw from the painful
stimulus (Clifford et al., 2004). The preterm infant has a lower
threshold for initiation of this flex response. An infant who
receives a muscle-paralyzing agent such a vecuronium will be
unable to mount a behavioral or visible pain response.
Physiologic or autonomic responses. Significant
changes in heart rate, BP (increased or decreased), intracranial
pressure, vagal tone, respiratory rate, and oxygen saturation
occur during noxious stimulation (Walden & Franck, 2003).
Metabolic responses. Infants release epinephrine,
norepinephrine, glucagon, corticosterone, cortisol, 11-deoxycorticosterone, lactate, pyruvate, and glucose (Walden &
Franck, 2003).
In assessing pain, the care provider needs to consider the
health of the neonate, the type and duration of the painful
stimulus, environmental factors, and the infants state of
alertness. For example, severely compromised neonates may
be unable to generate a pain response, although they are, in
fact, experiencing pain.
Every patient should have an initial pain assessment as
well as a pain management plan; this includes newborns. The
National Association of Neonatal Nurses (NANN) (1999) developed practice guidelines stating that all nurses who care
for newborns should have education and competency validation in pain assessment. Pain should be assessed and documented on a regular basis.
Circumcision is painful. Handle the area gently.

Provide extra holding, feeding, and opportunities for nonnutritive sucking for a day or two.
Several pain assessment tools have been developed for

use with neonates. A combination of behavioral and physiologic indicators of pain are used to diagnose and differentiate infant pain levels. Tools that have been shown to
have validity and reliability include the Neonatal Infant Pain
Scale (NIPS) (Lawrence et al., 1993) and the Premature Infant Pain Profile (PIPP) (Stevens, Johnston, Petryshen, &
Taddio, 1996). A pain assessment tool used by nurses in the
NICU is the CRIES (Krechel & Bildner, 1995) (Table 19-3).
This tool was developed for use by nurses who work with
preterm and term infants. CRIES is an acronym for the
physiologic and behavioral indicators of pain used in the
tool: crying, requiring increased oxygen, increased vital signs,
expression, and sleeplessness. Each indicator is scored from
0 to 2. The total possible pain score, which represents the
worst pain, is 10. A pain score greater than 4 should be considered significant. This tool can be used on infants between
ages 32 weeks of gestation and 20 weeks after birth (Pasero,
2002).
Management of neonatal pain. The goals of the
management of neonatal pain are to (1) minimize the intensity, duration, and physiologic cost of the pain; and (2)
maximize the neonates ability to cope with and recover
from the pain (Walden & Franck, 2003). Nonpharmacologic
and pharmacologic strategies are used.
Nonpharmacologic management. Containment,
also known as swaddling, is effective in reducing excessive immature motor responses. This may provide comfort
through other senses, such as thermal, tactile, and proprioceptive senses. Nonnutritive sucking on a pacifier, with or
without sucrose, is a common comfort measure used with
newborns. Skin-to-skin contact with the mother during a
painful procedure can help to reduce pain. Combining these
nonpharmacologic methods results in greater pain reduction.
Distraction with visual, oral, auditory, or tactile stimulation
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19
603
TABLE 19-3
CRIES Neonatal Postoperative Pain Scale
Crying
Requires O2 for
saturation 95%
Increased vital signs
Expression
Sleepless
No
No
High pitched
30%
Inconsolable
30%
Heart rate and blood

pressure equal to or less
than preoperative
state
None
No
Heart rate and blood pressure

20% of preoperative state
Heart rate and blood

pressure 20%
of preoperative
state
Grimace and grunt
Constantly awake
Grimace
Wakes at frequent intervals
CODING TIPS FOR USING CRIES
Crying
Requires O2 for
saturation 95%
Increased vital signs
Expression
Sleepless
The characteristic cry of pain is high pitched.

If no cry or cry that is not high pitched, score 0.
If cry is high pitched but infant is easily consoled, score 1.
If cry is high pitched and infant is inconsolable, score 2.
Look for changes in oxygenation. Infants experiencing pain manifest decreases in oxygenation
as measured by tCO2 or oxygen saturation. (Consider other causes of changes in oxygenation, such as atelectasis, pneumothorax, oversedation.)
If no oxygen is required, score 0.
If 30% O2 is required, score 1.
If 30% O2 is required, score 2.
NOTE: Measure blood pressure last because this may wake child, causing difficulty with other
assessments. Use baseline preoperative parameters from a nonstressed period.
Multiply baseline heart rate (HR) 0.2, then add this to baseline HR to determine the HR that
is 20% over baseline. Do likewise for blood pressure (BP). Use mean BP.
If HR and BP are both unchanged or less than baseline, score 0.
If HR or BP is increased but increase is 20% of baseline, score 1.
If either one is increased 20% over baseline, score 2.
The facial expression most often associated with pain is a grimace. This may be characterized
by brow lowering, eyes squeezed shut, deepening of the nasolabial furrow, open lips and
mouth.
If no grimace is present, score 0.
If grimace alone is present, score 1.
If grimace and noncry vocalization grunt is present, score 2.
This is scored based on the infants state during the hour preceding this recorded score.
If the child has been continuously asleep, score 0.
If he or she has awakened at frequent intervals, score 1.
If he or she has been awake constantly, score 2.
Neonatal pain assessment tool developed at the University of Missouri-Columbia. From Krechel, S., & Bildner, J. (1995). CRIES: A new neonatal postoperative pain measurement score: Initial testing of validity and reliability. Paediatric Anaesthesia, 5(1), 53-61.
may be helpful in term or older infants (Clifford et al., 2004;

Walden & Franck, 2003).
Pharmacologic management Pharmacologic agents
are used to alleviate pain in neonates related to procedures.
Local anesthesia has become routine during procedures such
as chest tube insertion and circumcision. Topical anesthesia has been used for circumcision, lumbar puncture,
venipuncture, and heel sticks. Nonopioid analgesia (acetaminophen) is effective for mild to moderate pain from inflammatory conditions. Morphine and fentanyl are the most
widely used opioid analgesics for pharmacologic management of neonatal pain. Continuous or bolus intravenous infusion of opioids provides effective and safe pain control
(AAP Committee on Fetus and Newborn, 2000). Ketorolac
(Toradol) has been shown to be effective in the management
of postoperative neonatal pain (Burd & Tobias, 2002). Postoperative neonatal pain should be managed with aroundthe-clock dosing or use of a continual drip. Dosing as
needed (prn) is not considered to be an effective management of chronic or postoperative pain (Hummel & Puchalski, 2001). Traditional belief holds that the continued use
of opioids for neonates in the postoperative period results
in prolonged intubation. Consequently, traditional practice
is to discontinue all opioids several hours before and after
extubation, preventing pain relief. Furdon and colleagues
(1998) found that continuous opioid infusion in infants
without an underlying pulmonary or neurologic pathologic
condition actually shortened the time to extubation and
caused no problems of respiratory depression that required
reintubation.
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Other methods for managing neonatal pain are epidural

infusion, local and regional nerve blocks, and intradermal
or topical anesthetics (AAP Committee on Fetus and Newborn, 2000; Anand & International Evidence-Based Group
for Neonatal Pain, 2001). A concentrated sucrose solution,
especially when administered with a pacifier, can decrease
pain associated with heel lance and venipuncture (Blass
& Watt, 1999; Gradin et al., 2002; Stevens, Yamada, &
Ohlsson, 2004). Oral acetaminophen may be administered
for painful procedures such as circumcision, venous puncture, and heel stick.
Evaluation
Evaluation is based on the expected outcomes of care. The
plan is revised as needed, based on the evaluation findings.
CARE MANAGEMENT:
DISCHARGE PLANNING
AND TEACHING
Infant care activities can cause much anxiety for the new parent (see Plan of Care). Support from nursing staff members
can be an important factor in determining whether new
mothers seek and accept help in the future. Whether this is
the womans or couples first newborn or an adolescent
whose mother will be the primary caregiver, and whether or
not the parents attended parenthood preparation classes,
parents appreciate anticipatory guidance in the care of their
infant. The nurse should not try to cover all the content at
one time because the parents can be overwhelmed by too
much information and become anxious. However, because
early discharge of new mothers is currently common practice, it may be a problem for the nurse to teach all the content that is necessary. As a result, many institutions have developed home visitation programs that take the necessary
teaching to the new parents, although the hospital nurse still
provides most of the essential information for newborn care
(see Community Activity box).
To set priorities for teaching, the nurse follows parental
cues. Deficient knowledge should be identified before the
nurse begins to teach. The nurse can use a tool such as the
Infant Teaching/Discharge Record (Fig. 19-23) to identify
parental needs. Normal growth and development and the
changing needs of the infant (e.g., for stimulation, exercise,
and social contacts), as well as the topics that follow, should
be included during discharge planning with parents.
Temperature
The following topics should be reviewed:
The causes of elevation in body temperature (e.g., overwrapping, cold stress with resultant vasoconstriction,
or minimal response to infection) and the bodys response to extremes in environmental temperature
Signs to be reported, such as high or low temperatures
with accompanying fussiness, lethargy, irritability, poor
feeding, and crying
Ways to promote normal body temperature, such as

dressing the infant appropriately for the environmental
air temperature and protecting the infant from exposure to direct sunlight
Use of warm wraps or extra blankets in cold weather
Technique for taking the newborns axillary temperature
Respirations
Review the following points:
Normal variations in the rate and rhythm
Reflexes such as sneezing to clear the airway
Need to protect the infant from the following:
Exposure to people with upper respiratory tract infections and respiratory syncytial virus (RSV)
Exposure to secondhand tobacco smoke
Suffocation from loose bedding, water beds, and
beanbag chairs; drowning (in bath water); entrapment under excessive bedding or in soft bedding;
anything tied around the infants neck; poorly constructed playpens, bassinets, or cribs
Sleep positionon back when put to sleep
Aspiration pneumonia; symptoms of the common cold
A commonly aspirated substance is baby powder,
which usually is a mixture of talc (hydrous magnesium
silicate) and other silicates. Parents are advised that,
if they prefer to use a powder, a cornstarch preparation
can be substituted. Whenever a powder is used, it
should be placed in the caregivers hand and then applied to the skin, never sprinkled directly onto the skin.
Symptoms of the common cold include nasal congestion and excess drainage of mucus, coughing,
sneezing, difficulty in swallowing or breathing, decreased vigor in feeding, and low-grade fever. Advise
the parents on measures to help the infant, such as the
following:
Feeding smaller amounts more often to prevent
overtiring the infant
Holding the baby in an upright position to feed
For sleeping, raising the infants head and chest by
raising the mattress 30 degrees (do not use pillow)
Avoiding drafts; not overdressing the baby
Using only medications prescribed by a physician
Using nasal saline drops in each nostril and suctioning well with bulb syringe to decrease and relieve secretions
Feeding Schedules
Feeding practices and schedules for newborns are discussed
in Chapter 20.
Elimination
A review includes the following reminders:
Color of normal urine and number of voidings (6 to
8) to expect each day
Changes to be expected in the color of the stool (i.e.,
meconium to transitional to soft yellow or golden
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INFANT TEACHING/DISCHARGE RECORD

Our nursing staff wish to give you the information you want and need most during your stay
with us. Please look over the following list of educational topics and complete the form by
putting a check in the column that most applies to you, using the following scale:
1 = Most important to learn before I go home
IMPRINT AREA
2 = I would like to review
3 = I already know or am comfortable with
SELF-ASSESSMENT CHECKLIST
BABY CARE
Crying as Communication
Hiccoughs and Sneezing
Bath Sponge/Tub
Soaps
Nail Care
Cord Care
Skin Care/Diaper Rash
Diaper Change
Genitals
Circumcision Care
Uncircumcised Baby Care
Elimination
Axillary Temperature
Clothing
Positioning
Bulb Syringe/Choking
Handwashing
Environment
Car Seat
BREASTFEEDING
Latching on
Positioning Mom/Baby
Frequency & Lengths of
Care of Breasts/Nipples
Breast Pump/Pumping Storage
BOTTLE FEEDING
Latching on & Positioning
Positioning
Frequency & Lengths of
Formula Preparation
Mild (Dove, Neutrogena, baby care products.)

Emery board.
Keep dry. Fold diaper below cord. Cord falls off 12 weeks.
Air dry, zinc oxide. Call advice if no improvement in 2 days.
Wash girls front to back.
Vaginal carewhite or pink discharge, cheesy material, normal.
Remove Vaseline gauze after 4 if present. Vaseline applied to diaper as needed for 24.
No need to retract foreskin.
Meconium first, then seedy soft yellow. Urinates 68 times/day.
Normal axillary temp. 97.6 F. Call advice if over 100 F.
Flame retardant. Dress comfortably. Do not overdress.
Side or back, NOT STOMACH.
Keep within reach/use to clear nose and mouth.
Viruses and bacteria easily transmitted through hands. Wash frequently.
Smoke free, smoke detector.
Calif. Vehicle Code #27365.5. Follow manufacturers directions for installation.
See Breastfeeding Information Guide.
Breastfeeding. Demand feed, usually every 11/23 hours around the clock. Be flexible.
Frequency: 812 times in 24 hours.
Duration: 1015 minutes of swallowing at each breast each feeding.
Sore nipples: check latch, vary positions; air dry; shorter, more frequent nursing.
Breast engorgement: hot soaks or hot showers, hand express, frequent nursing.
Supplements: not necessary.
Bottle feeding. Demand feed, usually every 34 hours. Be sure tongue is under nipple.
Clean bottles and nipples with hot, soapy water or dishwasher.
No need to sterilize.
May use tap or bottled water to mix formula.
Refrigerate extra feeding in quantities taken per feeding.
Do not microwave formula.
Do not prop bottle.
Special instructions or comments:
Home Health referral:

Mother verbalizes understanding of discharge instructions.
MOTHERS SIGNATURE
RN INITIALS
M.R. #
DATE
RN SIGNATURE
Staple 1 Infant ID Band Here.
I acknowledge receipt of my baby and have received educational instructions and materials.
Date
DISCHARGE
Time
01737-2 (REV. 12-96)
Date/Time
Bath as needed.
RN SIGNATURE
DISCHARGE
PATIENT EDUCATION
Normal.
SEEK MEDICAL ADVICE FOR THE FOLLOWING:
ID BAND #
Hunger, pain from not burping or gas, need for diaper change, too warm, too cold.
Redness, discharge or foul odor from circumcision or umbilical cord.

Less than 4 wet diapers/day by 4 days old.
Less than 68 wet diapers/day by 6 days old.
Frequent, explosive, watery stools that soak through the diaper.
Axillary temperature of less than 97.4 F or greater than 100 F.
Poor feeding, weak suck, no interest in eating.
Yellow coloring of skin (jaundice) or whites of eyes.
Vomiting forcefully several times (not just spitting up).
Very irritable or excessive sleepiness.
RN INITIALS
To
CARRIED OUT BY
With
MOTHERS SIGNATURE
Mother
Nurse
NURSES SIGNATURE
DISTRIBUTION: WHITE = MOTHERS CHART CANARY = BABYS CHART PINK = MOTHER
Fig. 19-23
Infant Teaching/Discharge Record. (Courtesy Kaiser Permanente, Redwood City, CA.)
Nurse Int.
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THE NEWBORN
yellow) and the number of bowel evacuations, plus the

odor of stools for breastfed or bottle-fed infants (see
Chapter 20)
Expected pattern of stools in formula-fed infants may
be as few as one stool every other day after first few
weeks of life
Positioning and Holding

The AAP Task Force on Infant Sleep Position and Sudden
Infant Death Syndrome (2000), recommends placing the infant in the supine position during the first few months of
life to prevent sudden infant death syndrome (SIDS). The
prone position has been associated with an increased incidence of SIDS. Death rates from SIDS have decreased by
more than 40% in the United States since the original sleep
position statement recommending supine sleeping for all
newborns was made in 1992.
Anatomically, the infants shapea barrel chest and flat,

curveless spinemakes it easy for the infant to roll from the
side to the prone position; therefore the side-lying position
for sleep is not recommended. Care must also be taken to
prevent the infant from rolling off flat, unguarded surfaces.
When an infant is on such a surface, the parent or nurse who
must turn away from the infant even for a moment should
always keep one hand placed securely on the infant. The infant is always held securely with the head supported because
newborns are unable to maintain an erect head posture for
more than a few moments. Fig. 19-24 illustrates various positions for holding an infant with adequate support.
Rashes
Diaper rash
The warm, moist atmosphere in the diaper area provides an
optimal environment for Candida albicans growth; dermatitis
Fig. 19-24 Holding baby securely with support for head. A, Holding infant while moving infant from one place to another. Baby is undressed to show posture. B, Holding baby upright in
burping position. C, Football hold. D, Cradling hold. (A, Courtesy Kim Molloy, Knoxville, IA;
B, C, and D, courtesy Julie Perry Nelson, Gilbert, AZ.)
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appears in the perianal area, inguinal folds, and lower abdomen. The affected area is intensely erythematous with a
sharply demarcated, scalloped edge, often with numerous
satellite lesions that extend beyond the larger lesion. The
usual source of infection is from handling by persons who
do not practice adequate handwashing. It may also appear
2 to 3 days after an oral infection (thrush).
Therapy consists of applications of an anticandidal ointment, such as clotrimazole or miconazole, with each diaper
change. Sometimes the infant also is given an oral antifungal preparation such as nystatin or fluconazole to eliminate
any gastrointestinal source of infection.
Washing and drying the wet and soiled area and changing the diaper immediately after voiding or stooling will prevent and help treat diaper rash. Parents can be taught to expose the buttocks to air to help dry up diaper rash. Because
bacteria thrive in moist dark areas, exposing the skin to dry
air decreases bacterial proliferation. A skin barrier ointment
such as zinc oxide may be effective in preventing further excoriation, especially in the presence of loose stools or systemic gastrointestinal candidiasis; the latter will require
treatment with a systemic antifungal drug.
Other rashes
A rash on the cheeks may result from the infants scratching with long unclipped fingernails or from rubbing the face
against the crib sheets, particularly if regurgitated stomach
contents are not washed off promptly. The newborns skin begins a natural process of peeling and sloughing after birth. Dry
skin may be treated with a neutral pH lotion, but this should
be used sparingly. Newborn rash, erythema toxicum, is a common finding (see Chapter 18) and needs no treatment.
Nail Care
Fingernails and toenails should not be cut immediately after birth, but should be allowed to grow out far enough to
avoid cutting the attached skin. If needed, the infants hands
can be covered with loose-fitting mittens to prevent scratching the face. However, this should be avoided if possible, because mittens inhibit the infant from sucking on fingers for
self-consolation. Nails can be safely trimmed with manicure
scissors or infant nail clippers, cutting nails straight across.
Emery boards can be used to file nails. Nail care is most easily accomplished after bathing, when the nails are soft, or
when the infant is sleeping.
Clothing
Parents commonly ask how warmly they should dress their
infant. A simple rule of thumb is to dress the child as they
dress themselves, adding or subtracting clothes and wraps for
the child as necessary. A cotton shirt and diaper may be sufficient clothing for the young infant. A cap or bonnet is
needed to protect the scalp and minimize heat loss if the
weather is cool, or to protect against sunburn and shade the
eyes if it is sunny and hot. Wrapping the infant snugly in a
blanket maintains body temperature and promotes a feeling
of security. Overdressing in warm temperatures can cause
19
607
discomfort, as can underdressing in cold weather. Parents are

encouraged to dress the infant at all times in flame-retardant
clothing. Infant sunglasses are available to protect the infants
eyes when outdoors.
Infants have sensitive skin; therefore new clothes should
be washed before putting them on the infant. Baby clothes
should be washed separately with a mild detergent and hot
water. A double rinse usually removes traces of the potentially irritating cleansing agent or acid residue from urine or
stool. If possible, the clothing and bed linens are dried in
the sun to neutralize residue. Parents who have to use coinoperated machines in commercial laundries to wash and dry
clothes may find it expensive or impossible to wash and rinse
the babys clothes well.
Bedding requires frequent changing. The top of a plasticcoated mattress should be washed frequently, and the crib
or bassinet should be dusted with a damp cloth. The infants
toilet articles may be kept convenient for use in a box, basket, or plastic carrier.
Sleeping
Since 1992, the AAP has recommended that infants be
placed on their backs to sleep. This supine position is associated with a decreased risk of SIDS. Loose bedding should
be kept away from the infants face and head to avoid the
risk of suffocation (Pollack & Frohna, 2002).
Safety: Use of Car Seat
Infants should travel only in federally approved, rear-facing
safety seats that meet Federal Motor Vehicle Safety Standard
(FMVSS) 213 and that are secured in the rear seat (Fig. 19-25).
Parents should bring the car seat to the hospital before discharge for training on positioning and securing the infant as
well as proper installation of the car seat. Many hospitals have
staff that are specially trained and certified in car seat safety;
parents can also check with local fire, police, or highway patrol agencies for assistance with proper installation of car seats.
Fig. 19-25 Rear-facing car seat in rear seat of car. Infant

is placed in seat when going home from the hospital. (Courtesy Brian and Mayannyn Sallee, Las Vegas, NV.)
CD: SkillChanging a Diaper
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THE NEWBORN
Critical Thinking Exercise
Sudden Infant Death Syndrome and

Infant Sleep Position
Marlys gave birth to a full-term infant; she and Daniel are
being discharged today. The nurse has given her instructions about placing the baby on his back for sleep.
Marlys said that she had noticed that the nurses placed
Daniel on his side in the nursery and wondered why they
did that when she was instructed to place Daniel on his
back.
Michelle gave birth to Michael at 32 weeks. During the
stay in the nursery the nurses placed Michael on his abdomen to sleep. At discharge, Michelle was instructed to
place Michael on this back to sleep. Michelle asked why
she had to place Michael on his back to sleep when he
was used to sleeping on his abdomen. How should the
nurses respond to these questions?
1 EvidenceIs there sufficient evidence to draw conclusions about the safety and efficacy of the supine position for sleep in reducing the incidence of sudden infant death syndrome (SIDS)?
2 AssumptionsWhat assumptions can be made about
the following factors related to infant positioning?
a. Role modeling by nurses
b. Sleep position in the nursery versus sleep position
at home
c. Sleep position for preterm versus term infants
d. Nurses knowledge and use of research evidence
3 What implications and priorities for nursing care can
be drawn at this time?
4 Does the evidence objectively support your conclusion?
5 Are there alternative perspectives to your conclusion?
The safest area of the car is the back seat. A car seat that
faces the rear gives the best protection for the disproportionately weak neck and heavy head of an infant. In this
position, the force of a frontal crash is spread over the
head, neck, and back; the back of the car seat supports the
spine.
NURSE ALERT Infants should use a rear-facing car seat
from birth to 20 pounds and to 1 year of age. If the infant reaches the weight limit before the first birthday,
the rear-facing position should still be used. In cars
equipped with air bags, rear-facing infant seats must not
be placed in the front seat. Serious injury can occur if
the air bag inflates because these types of infant seats
fit closer to the dashboard.
The car seat is secured using the vehicle seat belt; the infant is secured using the harness system in the car seat. If the
infant must ride in the front seat, the air bag must be turned
off to prevent injury from the air bag (AAP Committee on
Injury and Poison Prevention, 2002).
Infants are positioned at a 45-degree angle in a car seat
to prevent slumping and subsequent airway obstruction.
Many seats allow for adjustment of seat angle. For seats that
are not adjustable, a tightly rolled newspaper, a solid-core

Styrofoam roll, or a firm roll of fabric can be placed under the car safety seat to place the infant at a 45-degree angle (AAP Committee on Injury and Poison Prevention,
2002).
Infants born at less than 37 weeks of gestation and with
birthweight less than 2500 g should be observed in a car seat
for a period of time (equal to the length of the car ride home)
before discharge. The infant is monitored for apnea, bradycardia, and a decrease in oxygen saturation. It may be necessary to place blanket rolls on either side of the infant for
support of the head and trunk. To prevent slumping, the
back-to-crotch strap distance should be 14 cm.
Nonnutritive Sucking
Sucking is the infants chief pleasure. However, sucking needs
may not be satisfied by breastfeeding or bottle-feeding alone.
In fact, sucking is such a strong need that infants who are deprived of sucking, such as those with a cleft lips, will suck
on their tongues. Some newborns are born with sucking pads
on their fingers that developed during in utero sucking. Several benefits of nonnutritive sucking have been demonstrated, such as an increased weight gain in preterm infants,
increased ability to maintain an organized state, and decreased crying.
Problems arise when parents are concerned about the
sucking of fingers, thumb, or pacifier and try to restrain this
natural tendency. Before giving advice, nurses should investigate the parents feelings and base the guidance they give
on the information solicited. For example, some parents may
see no problem with the use of a finger but may find the use
of a pacifier objectionable. In general, there is no need to restrain either practice, unless thumb sucking persists past
4 years of age or past the time when the permanent teeth erupt.
Parents are advised to consult with their pediatrician, pediatric dentist, or pediatric nurse practitioner about this topic.
A parents excessive use of the pacifier to calm the child
should also be explored, however. It is not unusual for parents
to place a pacifier in their infants mouth as soon as the infant
begins to cry, thus reinforcing a pattern of distress-relief.
If parents choose to let their child use a pacifier, they need
to be aware of certain safety considerations before purchasing
one. A homemade or poorly designed pacifier can be dangerous because the entire object may be aspirated if it is
small, or a portion may become lodged in the pharynx. Improvised pacifiers, such as those commonly made in hospitals from a padded nipple, also pose dangers because the
nipple may separate from the plastic collar and be aspirated.
Safe pacifiers are made of one piece that includes a shield
or flange large enough to prevent entry into the mouth and
a handle that can be grasped (Fig. 19-26).
Sponge Bathing, Cord Care,
and Skin Care
Bathing serves a number of purposes. It provides opportunities for (1) completely cleansing the infant, (2) observing
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often for signs of infection (e.g., foul odor, redness, and purulent discharge), granuloma (i.e., small, red, raw-appearing
polyp where the umbilical cord separates), bleeding, and discharge. The cord clamp is removed when the cord is dry, in
about 24 to 36 hours (see Fig. 19-5). The cord normally falls
off in 10 to 14 days after birth but may remain attached for
as long as 3 weeks in some cases.
Parents are instructed in appropriate home cord care (per
practitioner or institution protocol) and the expected time
of cord separation.
The Teaching Guidelines box contains information regarding sponge bathing, skin care, cord care, cutting nails,
and dressing the infant.
Fig. 19-26 Safe pacifiers for term and preterm infants.
Note one-piece construction, easily grasped handle, and large
shield with ventilation holes. (Courtesy Julie Perry Nelson,
Gilbert, AZ.)
the infants condition, (3) promoting comfort, and (4) parentchild-family socializing.
An important consideration in skin cleansing is a preservation of the skins acid mantle, which is formed from the
uppermost horny layer of the epidermis, sweat, superficial
fat, metabolic products, and external substances such as amniotic fluid and microorganisms. At birth the skin has a pH
of 6.4. Within 4 days the pH of the newborns skin surface
falls to within the bacteriostatic range (pH less than 5)
(Krebs, 1998). Consequently, only plain, warm water should
be used for the bath during that 4-day period. Alkaline soaps
(such as Ivory) and oils, powder, and lotions should not be
used during this time because they alter the acid mantle, thus
providing a medium for bacterial growth. Although the
sponging technique is generally used, bathing the newborn
by immersion has been found to allow less heat loss and provoke less crying; this is not advised, however, until the
umbilical cord falls off. A daily bath is not necessary for
achieving cleanliness and may do more harm by disrupting
the integrity of the newborns skin; cleansing the perineum
after a soiled diaper and daily cleansing of the face may suffice.
The umbilical cord begins to dry, shrivel, and blacken by
the second or third day of life depending in part on the
cleansing method used. The umbilicus should be inspected
Infant Follow-up Care

With shorter hospital stays, the focus and site of infant care
are changing. Home care may be provided either by a nurse
as part of the routine follow-up care of patients, or through
a visiting nurse or community health nurse referral service.
For infants discharged early, newborn home care is essential
(Teaching Guidelines box) (see also Chapter 3).
Parents should plan for their infants follow-up health care
at the following ages: within 3 days if early discharge to check
for status of jaundice, feeding, and elimination (see also Physiologic Jaundice, pp. 542 to 543 for follow-up guidelines);
2 to 4 weeks of age; then every 2 months until 6 to 7 months
of age; then every 3 months until 18 months; at 2 years; at
3 years; at preschool; and every 2 years thereafter.
Immunizations
The schedule for immunizations should be reviewed with
the parents. Hepatitis B vaccine is currently administered to
newborns before hospital discharge (depending on maternal
hepatitis B status) with parental permission.
Cardiopulmonary resuscitation
All personnel working with infants must have current infant cardiopulmonary resuscitation (CPR) certification. Parents should receive instruction in relieving airway obstruction (Emergency box) and CPR (Emergency box). Often
classes are offered in hospitals and clinics during the prenatal
period or to parents of newborns. Such instruction is especially important for parents whose infants were preterm or
had cardiac or respiratory problems. Babysitters also
should learn CPR.
COMMUNITY ACTIVITY
Investigate infant car seat safety laws in your
state. Find out age and weight guidelines for the
various types of safety seats. Where can parents
go to have their infant car seats checked for
proper installation? Are there programs in your

community to provide car seats for low income
families? What are hospitals in your area doing
to promote infant safety?
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TEACHING GUIDELINES
Sponge Bathing
FIT BATHS INTO FAMILYS SCHEDULE
Give a bath at any time convenient to you but not immediately after a feeding period because the increased
handling may cause regurgitation.
PREVENT HEAT LOSS
The temperature of the room should be 24 C (75 F), and

the bathing area should be free of drafts.
Control heat loss during the bath to conserve the infants
energy. Bathing the infant quickly, exposing only a portion of the body at a time, and drying thoroughly are all
parts of the bathing technique.
CD: SkillInfant Bathing
GATHER SUPPLIES AND CLOTHING BEFORE

STARTING
Clothing suitable for wearing indoors: diaper, shirt; stretch

suit or nightgown optional
Unscented, mild soap
Pins, if needed for diaper, closed and placed well out of
babys reach
Cotton balls
Towels for drying infant and a clean washcloth
Receiving blanket
Tub for water; fill only to 3 to 4 inches of water
Wash hair with baby wrapped to limit heat loss. (Courtesy

Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
BATHE THE BABY
Bring infant to bathing area when all supplies are ready.

Never leave the infant alone on bath table or in bath water, not even for a second! If you have to leave, take the
infant with you or put back into crib.
Test temperature of the water. It should feel pleasantly
warm to the inner wrist36.6 to 37.2C (98 to 99 F).
Do not hold infant under running waterwater temperature may change, and infant may be scalded or chilled
rapidly. Baby may be tub bathed after the cord drops off
and umbilicus and circumcised penis are completely
healed.
If sponge bathing is to be done, undress the baby and
wrap in a towel with the head exposed. Uncover the parts
of the body you are washing, taking care to keep the rest
of the baby covered as much as possible to prevent heat
loss.
Begin by washing the face with water; do not use soap
on the face. Cleanse the eyes from the inner canthus outward, using separate parts of a clean washcloth for each
eye. For the first 2 to 3 days, a discharge may result from
the reaction of the conjunctiva to the substance (erythromycin) used as a prophylactic measure against infection. Any discharge should be considered abnormal and
reported to the health care provider.
Cleanse ears and nose with twists of moistened cotton or
a corner of the washcloth. Do not use cotton-tipped swabs
because they may cause injury. The areas behind the ears
need daily cleansing.
Wash the body with mild soap; rinse and dry to decrease
heat loss. Place your hand under the shoulders and lift
gently to expose the neck, lift the chin, and wash the neck,
taking to care to cleanse between the skin folds. Wash between the fingers and toes, rinse and dry thoroughly.
Wash the genital area last.
If the hair is to be washed, begin by wrapping the infant

in a towel with the head exposed. Hold the infant in a football position with one hand, using the other hand to wash
the hair. Wash the scalp with water and mild soap and a
soft brush; rinse well and dry thoroughly. Scalp desquamation, called cradle cap, often can be prevented by
removing any scales with a fine-toothed comb or brush
after washing. If condition persists, the health care provider may prescribe an ointment to massage into the
scalp. A blow dryer is never used on an infant because
the temperature is too hot for a babys skin.
SKIN CARE
The skin of a newborn is sensitive and should be cleaned

only with water between baths. Soap is drying and its
use is limited to bathing. Creams, lotions, ointments, or
powders are not recommended. If the skin seems excessively dry during the first 2 to 3 weeks after birth, an
unscented, nonalcohol-based lotion may be used; it is
best to check with the health care provider for suggestions on skin care products. It may be advisable to launder baby clothes separately, using a mild laundry detergent (Dreft or Ivory Snow); clothes should be rinsed
twice with plain water.
The fragile skin can be injured by too vigorous cleansing. If stool or other debris has dried and caked on the
skin, soak the area to remove it. Do not attempt to rub
it off, because abrasion may result. Gentleness, patting
dry rather than rubbing, and use of a mild soap without
perfumes or coloring are recommended. Chemicals in
the coloring and perfume can cause rashes on sensitive
skin.
Babies are very prone to sunburn and should be kept out
of direct sunlight. Use of sunscreens should be discussed
with the health care provider.
Babies often develop rashes that are normal. Neonatal
acne resembles pimples and may appear at 2 to 4 weeks
of age, resolving without treatment by 6 to 8 months. Heat
rash is common in warm weather; this appears as a fine
red rash around creases or folds where the baby sweats.
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TEACHING GUIDELINEScontd
Sponge Bathing
the fingernails and toenails can be trimmed with manicure scissors or clippers; nails should be cut straight
across. The ideal time to do this is when the infant is
sleeping. Soft emery boards may be used to file the nails.
Nails should be kept short.
CARE OF THE CORD
Cleanse around base of the cord where it joins the skin

with soap and water. If the use of alcohol on the cord is
suggested, use cotton-tipped swabs dipped in alcohol to
cleanse the cord at the base where the cord meets the
skin; this should be done with each diaper change. Notify the health care provider of any odor, discharge, or skin
inflammation around the cord. The clamp is removed
when the cord is dry (approximately 24 hr). The diaper
should not cover the cord because a wet or soiled diaper
will slow or prevent drying of the cord and foster infection. When the cord drops off after a 10 to 14 days, small
drops of blood may be seen when the baby cries. This will
heal by itself. It is not dangerous.
CLEANSE GENITALS
NAIL CARE
Do not cut fingernails and toenails immediately after birth.

The nails have to grow out far enough from the skin so
that the skin is not cut by mistake. If the baby scratches
himself or herself, apply loosely fitted mitts over each of
the babys hands. Do so as a last resort, however, because
it interferes with the babys ability for self-consolation
sucking on thumb or finger. When the nails have grown,
Cleanse the genitals of infants daily and after voiding or

defecating. For girls the genitals may be cleansed by separating the labia and gently washing from the pubic area
to the anus. For uncircumcised boys, gently pull back (retract) the foreskin. Stop when resistance is felt. Wash and
rinse the tip (glans) with soap and warm water, and replace
the foreskin.The foreskin must be returned to its original position to prevent constriction and swelling. In most newborns, the inner layer of the foreskin adheres to the glans,
and the foreskin cannot be retracted. By age 3 years in 90%
of boys, the foreskin can be retracted easily without causing pain or trauma. For others, the foreskin is not retractable
until adolescence. As soon as the foreskin is partly retractable and the child is old enough, he can be taught selfcare. Once healed, the circumcised penis does not require
any special care other than cleansing with diaper changes.
TEACHING GUIDELINES
Newborn Home Care after Early Discharge*
Wet diapers: 6 to 8 per day

Breastfeeding: successful latch-on and feeding every 1.5
to 3 hours daily
Formula-feeding: successfully, voiding as noted above,
taking approximately 3 to 4 ounces every 3 to 4 hours daily
Circumcision: wash with warm water only; yellow exudate forming, nonbleeding, PlastiBell intact for 48 hours
Stools: at least one every 48 hours (bottle-feeding) or two
to three per day (breastfeeding)
Color: pink to ruddy when crying; pink centrally when at
rest or asleep
Activity: has four or five wakeful periods per day and
alerts to environmental sounds and voices
Jaundice: physiologic jaundice (not appearing in first 24
hours), feeding, voiding, and stooling as noted above, or
practitioner notification for suspicion of pathologic

jaundice (appears within 24 hours of birth, ABO/Rh problem suspected; hemolysis); decreased activity; poor feeding; dark orange skin color persisting beyond fifth day in
light-skinned newborn
Cord: kept above diaper line; drying; periumbilical area
skin pink (erythematous circle at umbilical site may be
sign of omphalitis)
Vital signs: heart rate 120 to 140 beats/min at rest; respiratory rate 30 to 55 breaths/min at rest without evidence
of retractions, grunting, or nasal flaring; temperature 36.5
to 37.2 C axillary
Position of sleep: back
From Hockenberry, M. (2003). Wongs nursing care of infants and children (7th ed.). St. Louis: Mosby.
*Any deviation from the above or suspicion of poor newborn adaptation should be reported to the practitioner at once.
612
UNIT SIX
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11:01 AM
Page 612
THE NEWBORN
EMERGENCY
Relieving Airway Obstruction
Back blow and chest thrusts are used to clear an airway

obstructed by a foreign body.
Position the infant prone over forearm with the head

down and the infants jaw firmly supported.
Rest the supporting arm on the thigh.
Deliver four back blows forcefully between the infants
shoulder blades with the heel of the free hand.
Place the free hand on the infants back to sandwich the

baby between both hands; one hand supports the neck,
jaw, and chest, while the other supports the back.
Turn the infant over, and place the head lower than the
chest, supporting the head and neck.
Alternative position: Place the infant face down on your
lap with the head lower than the trunk; firmly support
the head. Apply back blows, and then turn the infant as
a unit.
Provide four downward chest thrusts on the lower third

of the sternum.
Remove foreign body, if it is visible.
OPEN AIRWAY
TURN INFANT
BACK BLOWS
CHEST THRUSTS
Open airway with the head tiltchin lift maneuver, and

attempt to ventilate.
Repeat the sequence of back blows, turning, and chest
thrusts.
Continue these emergency procedures until signs of recovery occur:
Palpable peripheral pulses return.
The pupils become normal in size and are
responsive to light.
Mottling and cyanosis disappear.
Record the time and duration of the procedure and the
effects of this intervention.
Back blows and chest thrust in infant to clear airway obstruction. A, Back blow. B, Chest
thrust.
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Page 613
CHAPTER
19
613
EMERGENCY
Cardiopulmonary Resuscitation (CPR)
CIRCULATION
Wash hands before and after touching infant and equipment. Wear gloves, if possible.
ASSESS RESPONSIVENESS
Observe color; tap or gently shake shoulders.

Yell for help; if alone, perform CPR for 1 min before calling for help again.
POSITION INFANT
Turn the infant onto back, supporting the head and

neck.
Place the infant on firm, flat surface.
AIRWAY
Open the airway with the head tilt-chin lift method.

Place one hand on the infants forehead, and tilt the
head back.
Place the fingers of other hand under the bone of the
lower jaw at the chin.
BREATHING
Assess for evidence of breathing:

Observe for chest movement.
Listen for exhaled air.
Feel for exhaled air flow.
To breathe for infant:
Take a breath.
Place mouth over the infants nose and mouth to
create a seal. NOTE: When available, a mask with a
one-way valve should be used.
Give two slow breaths (1 to 1.5 sec/breath), pausing to inhale between breaths. Note: Gently puff
the volume of air in your cheeks into infant. Do not
force air.
The infants chest should rise slightly with each puff;
keep fingers on the chest wall to sense air entry.
Assess circulation:
Check pulse of the brachial artery while maintaining the head tilt.
If the pulse is present, initiate rescue breathing.
Continue doing once every 3 sec or 20 times/min
until spontaneous breathing resumes.
If the pulse is absent, initiate chest compressions
and coordinate them with breathing.
Chest compression
There are two systems of chest compression.
Nurses should know both methods.
Maintain the head tilt and
1. Place thumbs side-by-side in the middle third
of the sternum with fingers around the chest
and supporting the back.
Compress the sternum 1.25 to 2 cm.
2. Place index finger of hand just under an imaginary line drawn between the nipples. Place the
middle and ring fingers on the sternum adjacent to the index finger.
Using the middle and ring fingers, compress
the sternum approximately 1.25 to 2.5 cm.
Avoid compressing the xiphoid process.
Release the pressure without moving the thumbs and
fingers from the chest.
Repeat at least 100 times/min, doing five compressions
in 3 sec or less.
Perform 10 cycles of five compressions and one ventilation.
After the cycles, check the brachial artery to determine
whether there is a pulse.
Discontinue compressions when the infants spontaneous heart rate reaches or exceeds 80 beats/min.
Record the time and duration of the procedure and the
effects of intervention.
A, Opening airway with head tiltchin lift method. B, Checking pulse of brachial artery. C, Side-byside thumb placement for chest compression in newborn.
Source: Stapleton, E. et al. (2001). Fundamentals of BLS for healthcare providers. Dallas, TX: American Heart Association.
614
UNIT SIX
11/15/05
11:09 AM
Page 614
THE NEWBORN
Key Points
Assessment of the newborn requires data from

the prenatal, intrapartal, and postnatal periods.
Nursing care of the newborn may include diagnostic and therapeutic procedures.
The newborn assessment should proceed systematically so that each system is thoroughly evaluated.
Gestational assessment should be completed

within 12 hours of birth for infants with less than
26 weeks of gestation and within 48 hours of birth
for infants with at least 26 weeks of gestation.
Providing a protective environment is a key responsibility of the nurse and includes such measures as careful identification procedures, support
of physiologic functions, measures to prevent infection, and restraining techniques.
The immediate nursing assessment of the newborn includes Apgar scoring and a general evaluation of physical status.
Circumcision is an elective surgical procedure.
Instruction in infant CPR is often provided to new

parents.
Nursing care of the newborn immediately after

birth includes maintaining a patent airway, preventing heat loss, stabilizing the infant, and promoting parent-infant interaction.
Pain in neonates must be assessed and managed.

Anticipatory guidance helps prepare new parents
for what to expect after hospital discharge.
Answer Guidelines to Critical Thinking Exercise

Sudden Infant Death Syndrome and
Infant Sleep Position
1 Yes, there is ample evidence that the supine position for sleep
reduces the incidence of sudden infant death syndrome (SIDS).
The nurses should cite the evidence as well as explain that in
preterm infants, use of the prone position can assist breathing
in the early phases of recovery from respiratory distress. However, as the infant matures, he should be placed on his back to
sleep.
2 a. Role modeling by nurses is a powerful teacher. Stastny and
colleagues (2004) found that only 30% of nursery staff placed
babies on their backs to sleep and cited fear of aspiration as
the reason. Continued staff education is necessary to promote the use of the supine position for sleep.
b. In the newborn nursery, nurses may place an infant on his
or her side to promote drainage of secretions, although there
is no evidence that this is effective. In the neonatal intensive care unit (NICU), infants in respiratory distress may
breathe more easily in the prone position. As the distress
lessens and the infant matures, the infant should be placed
on his or her back for sleep. Parents should be counseled to
place infants on their backs for sleep. During waking hours,
while the parent is supervising, the infant can be placed on
his or her side or abdomen.
c. Discuss sleep position for preterm versus term infants. Preterm infants may be placed in prone position to facilitate respiration; however, they should be on a cardiorespiratory
monitor.
d. Not all nurses read research reports and use research evidence
in their practices. Therefore they do not place infants on
their backs to sleep and do not instruct parents in sleep positioning. Continuing education programs for nurses working in nurseries should address the latest findings related to
the prevention of SIDS by use of positioning infants on their
backs to sleep.
3 The nurse needs to reinforce the importance of placing the infant on his or her back to sleep and discuss with the parents the
acceptability of placing the infant on the side or abdomen while
the infant is awake. The nurse can also advocate for continuing education programs for the nurses to update their clinical
knowledge. Signs could be posted in the nursery to remind
nurses of the correct positioning.
4 There is ample evidence of the efficacy of sleeping on the back
in prevention of SIDS. There is also documentation that many
nurses do not follow these recommendations. Stastny and colleagues (2004) found that Latina and Pacific Islander mothers
were less likely than Caucasian mothers to be instructed in positioning the infant on his or her back to sleep.
5 Nursery nurses may have had experience with babies choking
on mucus and used the prone or side-lying position to promote
drainage of mucus. Based on that experience, they may fear that
the back-lying position will promote aspiration. They may rely
on experience rather than research evidence in their care of infants. Continuing education programs should address research
findings. Nurse managers can implement programs of reward
for those nurses who base their practice on evidence.
Resources
American Academy of Pediatrics (AAP)
Air Bag Safety Sheets
141 Northwest Point Blvd.
Elk Grove, IL 60007
847-228-5005
www.aap.org
National Healthy Mothers, Healthy Babies Coalition

121 North Washington St., Suite 300
Alexandria, VA 22314
703-836-6110
www.hmhb.org
11/30/05
11:01 AM
Page 615
CHAPTER
National Institute of Child Health and Human Development

(NICHD)
National Institutes of Health
9000 Rockville Pike
Bldg. 31, Room 2A32
Bethesda, MD 20892
301-496-4000
www.nih.gov
Neonatal Network
1410 Neotomas Ave., Suite 107
Santa Rosa, CA 95405
www.neonatalnetwork.com
Resources for Parents

At-Home Dad (newsletter for fathers who stay at home)
61 Brightwood Ave.
North Andover, MA 01845-1702
E-mail: athomedad@aol.com
The Fatherhood Project at the Families and Work Institute
330 Seventh Ave.
New York, NY 10001
212-465-2044
Infant Massage: A Handbook for Loving Parents
Vimala McClure
International Association of Infant Massage (IAIM)
800-248-5432
The Institute for Responsible Fatherhood and Family Revitalization
1146 19th St., NW
Suite 800
Washington, DC 20036
800-732-8437 or 800-7-FATHER
19
615
La Leche League International (Local La Leche League groups are

usually listed in city and town phone books)
1400 North Meacham Rd.
Schaumburg, IL 60168-4079
847-519-7730
Motherhood Maternity Health and Fitness Program
SBI Corporation
1106 Stratford Dr.
Carlisle, PA 17013
717-258-4641
Pink Inc! Publishing
P.O. Box 866
Atlantic Beach, FL 32233-0866
904-731-7120
Postpartum Support International
927 North Kellogg Ave.
Santa Barbara, CA 93111
805-967-7636
Protecting Your Newborn, Video and Instructors Guide (1997)
Ford Motor Company and the U.S. Department of Transportation
National Highway Traffic Safety Administration (NHTSA)
Auto Safety Hotline 800-424-9393
www.nhtsa.dot.gov
Single Parent Resource Center
141 West 28th St.
Suite 302
New York, NY 10001
212-947-0221
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Describe the purpose and components of the

Discuss phototherapy and the guidelines for

KEY TERMS AND DEFINITIONS

ophthalmia neonatorum Infection in the neonates

or on the interactive companion CD

Initial Physical Assessment

[ ] moves extremities, muscle tone good

Assessment and Care of the Newborn

(4) reflex irritability, based on response to gentle slaps on

Initial Physical Assessment

other adventitious sounds; note equality of breath

5. Genitourinary: Note external sex characteristics and any

Assessment and Care of the Newborn

Physical Assessment of Newborn

Vertex: arms, legs in moderate flexion; fists clenched

Visible pulsations in left

Peripheral pulses equal and

Weak or absent peripheral

Decreased cardiac output,

Axillary: 36.5 C to 37.2 C

Inspect newborn before disturbing

Heart rate and pulses:

Weak or absent femoral

Temperature not stabilized

Apneic episodes: 15 sec

Prematurity, infection, low

CD: VideoAssessment of the Newborn

Physical Assessment of Newborncontd

Breath sounds loud, clear,

Measure blood pressure

RDS, congenital diaphragmatic hernia, transient

Weigh at same time each

Weight loss 10% to 15%

Prematurity, small for

Assessment and Care of the Newborn

Physical Assessment of Newborncontd

Length from top of head to

Length, crown to rump. To determine total length, include

Measure head at greatest

Small head 32 cm: microcephaly

Maternal rubella, toxoplasmosis, cytomegalic inclusion disease, fused

Hemorrhage, spaceoccupying lesion

Physical Assessment of Newborncontd

Measure at nipple line

2-3 cm less than head circumference, averages between 30 and 33 cm

Circumference of chest. (Courtesy Marjorie Pyle, RNC, Lifecircle,

Measure above umbilicus

Same size as chest

Enlarging abdomen between feedings

Abdominal mass or blockage in intestinal tract

Assessment and Care of the Newborn

Physical Assessment of Newborncontd

Petechiae over presenting

Petechiae over any other

Clotting factor deficiency,

Jaundice within first 24 hr

Mongolian spot (see Fig.

Opacity: few large blood

Gently pinch skin between

Dehydration: loss of weight

Edema on hands, feet; pitting over tibia

Tense, tight, shiny skin

Over shoulders, pinnas of