Chapter 18: Care for the Normal Newborn

Discuss strategies to prevent neonatal infection and injury:

Vitamin K (for injury) Infection- hand-washing, no rectal temps (can bring pathogens into the body system)

Conditions that may warrant further assessment:

**Down syndrome: Found during assessment of the head when the nurse notes a flattened occiput, a broad nasal bridge, upward slanted eyes with epicanthal folds, low-set ears, or enlarged tongue, high arched palate, and small chin. ** Eye: Sclera is blue may indicate a congenital condition known as osteogenesis imperfecta, which is characterized by a loss of bone structure and integrity. Yellow sclera may indicate elevated bilirubin levels Microcephaly- small head; releated to alcohol related birth defects After birth, from alcohol defects, babies are jittery, irritable, and poor feeders.

Demonstrate how to perform a newborn physical assessment: Immediate Neonatal Assessment: Infection and Injury Prevention:

**Hand-washing is essential in preventing cross-contamination by all individuals caring the the newborn.** Nursery personnel are required to wear wash scrubs, remove nail polish, and keep fingernails trimmed. Prevent infection: infant bathing, umbilical cord care, care of the circumcision, and eye care. Soon after birth, newborn receives a prophylactic ophthalmic agent to prevent ophthalmia neonatorum, eye inflammation from gonorrheal or chlamydial infection contracted during passage. Meds (erythromycin, tetracycline, silver nitrate) **During the first few days of life, the newborn has low levels of Vitamin K because of sterile intestinal contents. Vitamin K acts as a catalyst to synthesize prothrombin, needed for clotting, in the liver. To prevent neonatal injury caused by hemorrhage, a single dose (0.5-1.0 mg) of Vitamin K phytonadione (AquaMEPHYTON) administered via IM injection in the vastus lateralis or ventrogluteal muscle. ** **Vaccination for Hep B, given in a series of three doses at beginning of birth, is recommended for all infants. Must be given within 12 hours of birth. Need parental consent for this vaccine. ** **Assessment of blood glucose helps to prevent newborn injury related to hypoglycemia. In healthy term infants after an uneventful pregnancy and delivery, blood glucose monitoring often takes place within the first hour after birth. During the early newborn period of a term infant, hypoglycemia is defined as a blood glucose concentration of less than 35 mg/dL or a plasma concentration of less than 40 mg/dL. ** **Infants with a low blood glucose level or those who exhibit signs and symptoms of hypoglycemia (jitteriness, apnea, seizures, brain cell damage). Hypogylcemia usually resolved with feeding. If newborn continues to display signs and symptoms of hypoglycemia along with low blood glucose lab levels, transfer to NIC for IV administration** A heel stick blood sample for hematocrit and hemoglobin may be performed to detect anemia or polycythemia. Anemia can result from hypovolemia, placenta previa, abruptio placentae, or C-section. ** A normal Hematocrit at 1 hour of life is 46%-55%** ** Normal Hemoglobin is 15.2 to 22.5 g/dL.**

Demonstrate how to perform a newborn physical assessment: Immediate Neonatal Assessment Continued:

**Nurse remains alert for any signs of respiratory difficulty, such as rib or sternal retractions, "grunting" sounds or nasal flaring. ** To check heart rate: nurse places the thumb and two fingers at the base of the umbilical cord and counts the pulsations. Infant body temperature may be assessed by recording the axillary temp or by attaching a thermoprobe and recording monitor to the skin. **Obvious abnormalities are noted, and the nurse also checks and records the number of vessels in the umbilical cord (2 arteries; 1 vein). If neonate has only 2 vessels (1 artery, 1 vein, HCP contacted STAT may be associated with renal and cardiac anomalies)** Infants weight and length are determined and recorded. **A numerical APGAR score is assigned at 1 and 5 minutes after birth (measures adaptation to extrauterine life) ** **APGAR (5 components): Respirations, Reflex irritability, Skin color, Muscle tone, & Heart Rate)** **When APGAR score is less than 9 @ 5 minutes of life, it is important to stabilize the infant rather than allowing him to remain with his mother in the birthing unit.** **IMMEDIATE INFANT STABILIZATION**>> nasal flaring, grunting respirations, rib retractions, heart rate less than 120 bpm or greater than 160 bpm, pallor, serious congenital anomalies, preterm infant (less than 38 weeks), infant of a diabetic mother, or an infant who appears to be small for gestational age.

Demonstrate how to perform a newborn physical assessment: Immediate Neonatal Assessment Identification

After the apgar evaluation, nurse completes the mother-infant identification process according to hospital policy. Includes obtaining footprints and a fingerprint and a thumbprint of the mother along with appropriate labeling. Two bracelets worn by neonate while others are worn by her and her partner.

Musculoskeletal Common Findings:

After visual insepction, the nurse begins palpation of the muscloskeletal system. Starting with the shoulders, the examination progresses downward toward the lower extremities. Rotation of the neck is first and most important rotation assessed. Failure to achieve full rotation may be r/t to torticollis or the congenital absence of portions of the cervical vertebrae. To assess head lag, the nurse carefully pulls the infant up while watching the head gently fall back. This maneuver also provides an opportunity to inspect the neck for bulging of the thyroid gland and for assessing the muscle tone of the upper body along with should and arm strength. Nurses next direction is toward the assessment of the hip joint, the SECOND most important joint evaluation. Developmental dysplasis of the hip (DDH)- is a congenital condition that, if left untreated, can affect the infant's future ability to walk and maintain balance. This occurs when the acetabulum is flat, rather than round and cup-like in shape. Asymmetry of the skin folds may signal the presence of hip dysplasia. Nurse also assess the leg length and knee height for uneveness. Next, the nurse slowly moves the infant's lower extremities in a kicking motion while observing for signs of pain or distress.

Assessment of the Cardiovascular System:

Assess by inspection and auscultation. Careful inspection of the skin, lips, gums and buccal mucosa provides reliable evidence for cardiac perfusion. At rest, the infant's skin should be pink in color and progress to red during crying or physical activity. Nurse palpates the chest to detect any thrills or heaves and the point of maximum impulse, which is auscultated at the apex of the heart near the 3rd or 4th intercostal space. **For infants: Normal heart rate: 120-160 bpm** Heart rate greater than 160 bpm is termed tachycardia. To assess capillary refill in extremities, the nurse gently pinches the end of the infants finger or toe and then counts the # of seconds required for the skin to return to its normal color. Average refill time is 3 seconds. If more than 3 seconds lapse, there may be shunting of blood from the periphery toward the infant's trunk. Nurse palpates all peripheral pulses for bilateral symmetry, strength, and rate. Femoral pulses on each side are carefully checked and compared with brachial pulses. If a decrease in strength of the pulse between its brachial pulses and femoral pulses is noted, this finding may be indicative of coarctation of the aorta, a cardiac condition associated with a narrowing of the aortic arch. HR > 160 = tachy HR< 100=brady It is normal to hear murmurs in infants less than 24 hours old. Murmurs are best heard near the sternal border at the second or third intercostal space on the left side. Infants who demonstrate cardiac instability within the first 2 days of life are usually those with a genetic karyotype {tetralogy of Fallot}. Tetralogy of Fallot is a congenital heart defect that involves four distinct cardiac anomalies: transportation of the aorta and pulmonary artery, right ventricular hypertrophy, pulmonary stenosis, and ventricular septal defect.

Demonstrate how to perform a newborn physical assessment: Assessment of the Infant's Head: Nose

Assessment of the nose begins with an observation of the placement of the nose. Nurse can draw an imaginary line from the center of the bridge of the nose downward to the notch of the upper lip. Nose should lie exactly vertical to this line. Each side of the nose should be symmetrical. Important to note any deviation to one side as well as asymmetry.

Critical nursing action: Recognizing imperforated anus

Clinical manifestations from the situation on pg. 687 No meconium stool since birth 26 hours ago Abdomen appears distended and feels firm on palpation

Conditions that may warrant further assessment about musculoskeletal:

Before performing musculoskeletal system, the nurse first must determine that there is no broken bones. it is important that the infant not to be moved or repositioned until this has been accomplished. Nurse should palpate the clavicles to check for a separation between the bone ends or for the presence of crepitus. Signs and symptoms of fractures include swelling at the fracture site, bruising, or discoloration of the affected area of the infant's expression of discomfort when moved. Clavicular fractures heal over time without intervention, and the nurse can teach the parents to position the infant on the side opposite of the injury and how to hold and support the infant's head and shoulders until healing is complete. Polydactyly- infants born with extra fingers/toes Syndactyly- webbing of the skin between the fingers/toes Simian crease- is a single straight crease that appears in the middle of the palm on one or both hands. When unaccompanied by other findings, the simian crease is insignificant. When detected with other symptoms, a simian crease may be associated with other sydromes such as Down syndrome.

Assessment of musculoskeletal system:

Can observe this while infant is in the crib By flexing and extending the arms and legs, sucking on the fingers, and moving the head side-to-side the neonate provides a visual display of musculoskeletal status. Inspection of extremities for differences in length or size is important. Positive findings could be indicative pf achondroplasia, a congential condition characterized by a small thoracic area, an inability to extend the elbows, and a marked shortening of femurs and humerus. To assess muscle tone and strenght, the nurse first places the infant in a supine position and then in a prone position. If infant is unable to move the lower extremities, damage to the spinal cord is suspected. Asymmetry in movement suggests nerve damage or fracture related to birth trauma. If the infant does not move, or appears floppy when repositioned, the nurse suspects hypotonia or decreased muscle tone. Hypotonia may be r/t an episode of anoxia, either during birth or while in the utero. Increased muscle tone, or hypertonia, is characterized by muscle tremors, twitches, or jerkiness, and this finding is often associated with neonatal abstinence syndrome. Symptoms of drug withdrawal are manifest through the increased muscular movements.

Demonstrate how to perform a newborn physical assessment: Assessment of the Infant's Head Continued:

Caput succedaneum- diffuse edema that crosses the cranial suture lines and disappears without treating during the first few days of life. Cephalhematoma- more serious condition; results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant's head and persists for weeks while the tissue fluid is slowly broken down and absorbed. During this time, the infant may exhibit signs of jaundice related to the metabolism of damaged RBC's from the subperiosteal hemorrhage. Eyelids are manually opened and the iris, sclera, and conjuctiva are examined. It is not unusual to detect tiny pinpoint scleral hemorrhages (r/t birth trauma). Swollen eyelids and yellow discharge that adheres to the eyelashes may provide evidence of eye prophylaxis medication. Epstein pearls- whitish hardened nodules on the gums or roof of the mouth, may be visualized or palpated. Not unusual findings and disappear within a few weeks. Infants ability to suck can also be assessed. Nurse inserts a gloved finger into the infants mouth and notes and records (strength and sucking motion) Hard and soft palates also assessed for size, shape, and cleft formations. When present, a cleft defect is felt as an open space or as a notched ridge. A high arched palate may be associated with difficulty swallowing or with later speech development. Gag reflex is elicited, and the back and throat, tongue, uvula are specialized. Infants throat is palpated to check for an enlargement of the thyroid and to ensure the trachea is midline. Chin lifted to assess the neck area for skin folds. Nurse checks for neck rotation by observing infant's head movement and by gently turning the head from side-to-side. **Torticollis is a deviation of the neck to one side caused by a spasmodic contraction of neck muscles. This is apparent when the head is positioned on one side while the chin points to the opposite side.**

Common Findings in Genitourinary system:

Careful assessment of genitalia is essential in both males and females. First the nurse inspects and then palpates male genitalia. Infants of various ethnic backgrounds, especially those of African American backgrounds, have dark colored scrotal skin. Scrotal swelling may interfere with an accurate palpation. If swelling is present, it is important to auscultate the scrotum to ensure that it does not hold entrapped bowel. Smegma, a waxy subtance, may be present on the glans beneath the foreskin on male genitalia. Instead of the normal round urethral opening, or meatus, a vertical opening may be seen. When present on the ventral surface (instead of central), this finding is indicative of hypospadias. This requires surgical repair by a physician. Males with hypospadias should NOT be circumcised. Epispadias is a similar condition and should be surgically repaired. During inspection of the female genitalia, the nurse may identify vernix caseosa, a whitish cheesy substance, covering the tissue between the labia. This is a normal finding. Small amounts of blood and whitish mucoid discharge ("pseudomenstruation"), related to maternal hormones, may be noted in the vaginal area. This discharge is normal and will disappear.

Assessment of the Integumentary System: Continued

Cutis marmorata or mottling is common in neonates and most often caused by the infant's vasomotor response to the lower environmental temperature outside the uterus. May be r/t prolonged apnea. Usually disappears as baby adapts to extrauterine environment. Birthmarks are distinct areas of color that may be tan, brown, white, or red. Their appearance varies but generally these lesions are small and flat. It is important to distinguish birthmarks from skin lesions that result from birth trauma. **Cafe-au-lait birthmarks are flat, tan spots that are quite common and insignificant unless the infant exhibits 6 or more marks greater than 1 cm in diameter. (Hard to identify on African-American babies) ** Brown nevi- are brown skin marks who color can vary from brown to deep black. Nevus flammeus- birthmark often referred to as a port wine stain is a capillary angioma located directly below the epidermis. Usually apparent at birth, the nervus flammeus is a non elevated, red to purple network of dense capillaries that varies in size, shape, and location. Sturge-Weber syndrome, a clinical rotation involving the 5th cranial nerve, may be present when a nevus flammeus is accompanied by convulsions or other indicators of neurological problems. Telangiectatic nevus- a red birthmark often seen at the nape of the neck and commonly referred as a "stork- bite" or "angel kiss" Nevus vasculosus- "strawberry mark" is a red, raised capillary hemangioma that can occur anywhere on the neonate's body. Blue nevus- appears as a distinct blue or blue-black birthmark often found on the buttocks,hands, and feet. Can be mistaken for a Mongolian spot when it appears on buttocks, but can differentiate the blue nevus by noting its distinct borders and brighter colors. Hypopigmentation- refers to a white or pale area of the skin

Conditions that may warrant further assessment: Musculoskeletal

Dystocia- identified by a temporary decrease in the movement and muscle tone of a shoulder and upper arm. Erb's palsy- one form of brachial plexus injury that is readily identified from the positioning of the infant's arm while in the supine position. When present, one or both arms are extended and do not move into a flexed position. ("Waiters position" Meningocele- lesion of spina bifibida resembles a skin-covered sac which may contain dura matter and spinal fluid. Myelomeningocele- a sac that contains dura mater, spinal fluid, and a portion of the spinal cord. Anencephaly-incomplete closure of the anterior portion of the neural tube.

Assessment of the Genitourinary System:

Infant in supine position with hips abducted. Palpation of the scrotum by placement of second finger at the posterior scrotal midline with thumb on anterior midline. Using the index finger and the thumb, the nurse palpates the left side of the scrotum for the presence of a testis and then uses the third finger and thumb to palpate for a testis on the right side of the scrotum. Proceeding in this pattern helps to ensure that one testis is not counted twice. Inspection of the female genitalia begins with the labia majora. For most term infants, the borders of the labia majora touch, and the clitoris is covered completely. Anus and anal opening are also assessed. While stooling confirms patency, it is beneficial to actually witness the passage of meconium because it provides an opportunity for the nurse to confirm that the stool passes through only one opening. Stool in the vagina indicates the presence of a rectovaginal fistula, an opening between rectum and vagina. To palpate the anus, the nurse gently touches the tissue around the anal opening. Tiny rectal tears from the passage of stool in the anal ring are noted, and the anal wink reflex is assessed. The infant is placed in a prone position and, using the index finger, the nurse gently strokes the buttocks from side to side. In response, the buttocks draw together and "wink" at the point of anal opening.

Demonstrate how to perform a newborn physical assessment: Later Neonatal Assessment: Level of Reactivity

Infant's reaction to the environment is an important indicator of the level of neuromuscular develop. Important to consider these questions: -Is neonate awake and quiet, or restless and crying? -Does the infant respond by looking and moving all extremities? -Is the infant's sleep pattern best characterized by quiet slumber or agitated restlessness? Neonates exhibit several discrete behavioral levels or "states" of awareness and normally progress or regress smoothly from one to the other. Sleep statues include deep sleep and rapid eye movement sleep; the alert states include drowsy, quiet, alert, active alert, and crying. Neonates behavioral assessment is an important component of the overall evaluation because it validates a mature neurological-organizational system that allows the term infant to readily transition from one behavioral state to the next. Nurse may assess the infants response to voices and physical presence to confirm the level of responsiveness and behavioral organization. An infant who displays irritability and an overreaction to voices, touch, or movement needs to be comforted and special care must be taken to provide calming measures such as swaddling the neonate in blankets, cuddling, rocking, and gentle holding.

Demonstrate how to perform a newborn physical assessment: Assessment of the Infant's Head: Ears

Inspect and palpate the ears to determine the thickness of the ear lobe and pinna. Ear pits, tiny pinholes found near the upper curved border of the pinna, arise from the imperfect fusion of the tubercles of the first and second brachial arches during early fetal development. Because they may signal a small sinus tract between the skin and underlying structures, they should be carefully evaluated to determine whether a layer of skin covers the opening or if the pit is open @ the bottom. When signs of infection (redness, edema, or draining of fluid) are present, the ear pits should be surgically repaired. Ear tags, fleshy bulb-shaped growths that project from the surface of the skin, should be removed for cosmetic purposes by a plastic surgeon because they frequently contain microcapillaries that bleed when cut.

Critical Nursing Action: Recognizing Immediate Neonatal Respiratory Distress:

MUST NOTIFY PHYSICIAN IF: -Generalized cyanosis -Tachycardia (Heart rate > 160bpm -Tachypnea (respiratory rate greater than 170 bpm) -Rib retractions -Expiratory grunting -Flaring nostrils

Conditions that may warrant further assessment of genitourinary system:

Micropenis (less than 2 cm) may be indicative of a pituitary tumor. Clitoral enlargement could be r/t to excessive androgen production. The absence of an opening in the anal ring is a condition known as imperforate anus. This is an MEDICAL EMERGENCY "VATER": V-vertebral abnormalities A-anal abnormalities (imperforate anus) T-tracheal abnormalities E-esophageal abnormalities R-renal and radial abnormalities

Gastrointestinal system: Findings that may warrant further assessment:

Necrotizing enterocolitis- a life threatening condition that occurs when a lack of blood flow to the bowel results in destruction of the intestinal mucosa. Discharge from umbilical cord or cord site indicates the presence of an infection.

Demonstrate how to perform a newborn physical assessment: Later Neonatal Assessment: Obtaining Measurements and Determining Gestational Age

Neonates weight is recorded in grams Length recorded in centimeters **On average, a term newborn infant weighs 3400 grams, with a normal range of 2500 to 4300 grams.** Recumbent length is crown-to-heel measurement taken with the infant in a supine position. Recumbent length is measured on a regular basis until the infant reaches 24 months. **Normal length parameters for newborns are approx 18-22 inches (45-55 cm)** Nurse also obtains and records the frontal occipital circumference or head measure. A paper tape measure with increments marked in tenths of a centimeter is used to ensure an accurate measurement. After obtaining the head circumference 3 times, the nurse records the largest finding. **The normal head circumference for a full-term neonate ranges from 13-15 inches (33-38 cm). ** To obtain the chest circumference measurement, the paper tape measure is placed on the nipple line and then wrapped around the entire thoracic area. Head and chest may be equal during the first few days of life. **A normal chest measurement is 12-13 inches (30.5-33 cm)** The abdominal circumference may be obtained by encircling the infant's body with paper tape measure placed directly above the umbilicus. **Abdomen should be approx the same size as the chest**

Demonstrate how to perform a newborn physical assessment: Immediate Neonatal Assessment

Newborn's physical condition is assessed STAT. If necessary suctioning of the oral, pharyngeal or endotracheal area is conducted according to the health facility's policy. Infant is handed to nurse who receives neonate into a sterile baby blanket and, in the ideal situation, places him on the mother's abdomen to help maintain the baby's body temperature.

Demonstrate how to perform a newborn physical assessment: Later Neonatal Assessment: Body Positioning

Normal newborn baby assumes a position of flexion of the upper and lower extremities Flexed arms enable infants to use their hands to touch their faces, suck their fingers, and explore the world. Nurses should recognize that asymmetrical positioning at the times of assessment might indicate injury from birth trauma. **Critical nursing action**-- ALL INFANT SHOULD BE PLACED FOR SLEEP IN A SUPINE POSITION (ON THE BACK) FOR EVERY SLEEP BY CAREGIVER UNTIL 1 YEAR AFTER LIFE. SIDE SLEEPING IS NOT SAFE AND ADVISED!!!!

Demonstrate how to perform a newborn physical assessment: Later Neonatal Assessment: Skin Color

Normally, jaundice develops gradually over several days in a head-to-toe or cephalocaudal pattern. **Any term infant less than 24 hours old who demonstrates visual jaundice is considered to have pathological jaundice or hemolytic jaundice, a condition that most often results from a serious blood incompatibility.** It is best to assess newborn skin in natural daylight. When jaundice is suspected, the nurse can readily assess the skin color by pressing on the infant's forehead or nose with a finger. When blanching occurs, the nurse can observe for yellow coloration associated with jaundice. **Physiological jaundice or nonhemolytic jaundice describes the more commonly occurring yellowing of the skin in neonates that becomes apparent after the first 24 hours of life. This type of jaundice results from a failure to adequately process bilirubin because of inadequate intake or elimination, birth trauma, or minor blood incompatibilities.** **Breastfed infants develop early onset or breastfeeding associated jaundice which is associated with insufficient feeding and infrequent stooling. ** **Because colostrum has a natural laxative effect that stimulates passage of meconium, frequent breastfeeding during the early days of life is beneficial in reducing the neonates serum bilirubin levels. ** Nursing actions to decrease likelihood of high bilirubin levels: **Maintain infants skin temperature or at greater than 97.7** is beneficial because cold stress can cause acidosis. Careful monitoring if baby's I&O with special attention of frequency and characteristics of stool. Nurse should encourage early (within first hours of life) feedings when possible to promote rapid and continuous intestinal evacuation of hepatic binding proteins. Parents should be taught about the importance of adequate hydration and how to assess the infant for signs of jaundice. Parents should be encouraged to help meet their infant's emotional needs by holding, feeding, touching, and interacting with the baby. When the mother must leave the hospital without the baby, the nurse can support the bonding process by providing the nursery telephone number and names of the baby's primary caregivers. All infants should exhibit pink skin, which is an important indicator of satisfactory perfusion to the extremities. **Acrocyanosis, a common finding, is confined to the hands and feet. Neonates with central cyanosis may demonstrate a blue tint to the lips, gums, tongue, fingertips, and toes, as well as pallor under the eyes and on cheeks. Central cyanosis= contact HCP STAT. ** Observing how long it takes for the infant to return to the previous skin color after stimulation is an important component of the nurse's visual assessment of the neonates cardiovascular system.

Assessment of the Respiratory System:

Nurse first observes for symmetry in chest movement and at the same time notes the placement and size of breast tissue. Enlargement in breasts in male is common and only a temporary condition because it is related to maternal hormones. Nipples and breast tissue should be located in the midclavicular line. Presence of wide spaced nipples may signal a congenital syndrome, such as Down syndrome. To assess for nasal patency, the nurse carefully occludes one naris while the infant's mouth is closed. A rise in the infant's chest confirms the nasal passageway is open and the air is inhaled. If infant demonstrates difficulty with this manuever, he may have a developmental anomaly known as choanal atresia ( a malformation of the bucconasal membrane). When present bilaterally, cyanosis is noted when the infant's mouth is closed but disappears when the mouth is open. An inability to pass a small catheter into the nares confirms the diagnosis. Because choanal atresia may be associated with other developmental anomalies, a positive finding should be reported STAT. With infant in supine position, nurse can readily assess his ease with overall breathing efforts. Respirations are counted, and the pattern and any use of accessory muscles are noted. Slight sternal retractions may occur, and this is NORMAL. Prominence of xiphoid process is not unusual, and with normal growth and development, the prominence will diminish. Infant may exhibit irregular breathing patterns accompanied by periods of apnea that can persist for up to 15-20 seconds. This is common and we should reassure parents of this common respiration cessation. Signs of respiratory distress: flaring of nares, retraction (indrawing of tissues between the ribs, below the rib cage, or above the sternum and clavicles), or grunting with expiration. For healthy full-term neonates, a respiratory rate less than 60 bpm is considered normal.

Assessment of the neurological system:

Nurse focuses on the reflexes and other movements that provide an indication of the infant's level of neurological function. Two major reflex categories: Major reflexes (reflective of normal neurological function) Minor reflexes (finger and toe grasp, rooting, sucking, head righting, stepping, and tonic neck). Major reflexes include the gag, Babinksi, Moro, and Galant reflexes. Foot and toe grasp: Observed by placing an object at the site and watching the fingers/toes curl. Nurse observes the rooting and sucking reflex by stroking the infant's cheek and watching him turn toward the finger, open the mouth, and begin the sucking process. Head righting reflex: lifting neonate in the prone position and gently stroking the back in the midline along the spinal cord. The infant attempts to raise the head and arch the back at the same time. Stepping reflex: Nurse holds infant in an upright position with the legs flexed. Soles of feet are slightly brushed against a flat surface. In response to stimulation, infant lifts his feet and then places them back down in a step-wise pattern. Tonic neck or fencing reflex: Infant in a supine position, nurse observes the infant extend the arm and leg on the side to which the head and jaw are turned while flexing the arm and leg on the opposite side. Babinski reflex: Lightly stroking the plantar surface of the foot from the heel toward the toes, then uncurling and stretching them out. Moro reflex: As infant head is lifted, the nurse mimics a release and watches extension of both arms with flexion of the lefs, movements that confirm the Moro reflex. Galant Reflex: Also called the trunk incurvation reflex, is elicited as the infant is held or supported in a prone position. One side of the vertebral column is stroked. The infant responds to this stimulus by moving the buttocks in a curving motion toward the side that is being stroked.

Demonstrate how to perform a newborn physical assessment: Assessment of the Infant's Head

Nurse methodically assess face for symmetry, noting the placement of the eyes, nose, lips, mouth, and ears. Special attention is paid to the shape, size, and placement of the ears. Low-set ears may need further assessment for chromosomal abnormalities. Placement of one ear slightly lower than the other is common. Nostrils should be open bilaterally and nasal bridge should be centered with no lateral deviations. Lip color should be consistent with the tongue and buccal mucosa of the mouth. Infant's chin should be readily apparent when viewed in a profile position. Micrognathia or small jaw, may interfere with tooth development, sucking, swallowing, and tongue movement. Nurse carefully palpates the infant's head to assess the fontanelles, the cranial suture lines, and the presence of any birth-related edema. Anterior fontanelle is readily identifiable as a diamond-shaped open space formed by the anterior-posterior sagittal and frontal sutures and the lateral coronal structure. **Posterior Fontanelle is usually only 0.4 inch (1 cm) and may be closed by initial examination** Anterior fontanelle must remain open to accommodate skull bone expansion that accompanies normal brain growth Fontanelle assessment is important to check for intracranial pressure. Normal intracranial pressure is characterized by a finding of fontanelle fullness without bulging either on visual inspection or palpation. Bulging tense fontanelles in an infant with a large head circumference are indicative of increased intracranial pressure, often associated with hydrocephalus.

Describe 4 activities to foster early infant attachment:

Nurse must create a nonthreatening and nonjudgmental environment in which parents can openly express ideas and ask questions. An important concept for the nurse, mother, and other caregivers to understand is that healthy bonding is essential for adequate physical, emotional, and spiritual growth. -Begin by examining each finger-tip on the child (parents do this for early attachment) -Examine babies extremities -Stroke full length of baby's trunk -En face position (parent directly looks at child with infant in their hands to observe features) -Gentle touch

Assessment of Gastrointestinal system:

Nurse places infant in supine position Abdomen should be round and bilaterally symmetrical. The clamped umbilical cord should show no evidence of active bleeding or oozing. It is inspected to confirm the presence of 3 vessels (2 arteries, 1 vein) Wharton's jelly, the gelatinous substance that prevents compression of the blood vessels, may appear as areas of varying amounts of thickness. Abdomen may be distended because of the stool that has not been passed yet. Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines. The nurse completes the assessment with auscultation of the upper abdomen for the gastric bubble and the heart sounds of the abdominal aorta. Common findings: Light palpation is initiated @ the lower sternal border and proceeds along the midline down to the umbilicus. Diastasis rectus, a thinning of the abdominal wall may be detected. Diastasis rectus can also be identified by the presence of a long, raised "lump" along the midline that becomes prominent when the infant is crying. Nurse assess the area surrounding the umbilicus for the presence of an umbilical hernia. Using the fingertips to determine the hernia size, the nurse notes whether it appears to be large or small and documents this information in medical record. Small umbilical hernias are common newborns and often close without surgical intervention as the infant grows. Deep palpation facilitates examination of the organs. The border of the liver should be smooth and firm and located just below the right costal margin. The spleen, which lies beneath the left costal margin, should be palpable only at the tip. If a larger segment of spleen is palpated, this finding is a reason for concern because it is indicative of organ enlargment. Because of their small size, kidneys may be hard to detect. Located 1-2 cm above the umbilicus and are at the right angle to the umbilicus at the midline. Bladder should be present as a smooth organ in the midline below the umbilicus.

Demonstrate how to perform a newborn physical assessment: Later Neonatal Assessment: Body Size

Nurse visually inspects the infant for symmetry of head-to-toe length along with abdominal girth. As a component of the visual inspection, the nurse confirms that the infant's head appears to be the largest body part.

Normal Neonatal Patterns at birth:

Respirations: 30-60 breaths/min, irregular no retractions or grunting Apical pulse: 120-160 bpm Temp: 97.7-99.3 Skin color: Pink body, blue extremities Umbilical cord (2 arteries, 1 vein) Gestational age: Full term >37 completed weeks (should be 38-42 weeks to remain with parents for an extended time period) Weight: 2,500-4,300 grams Length: 45-54 cm

Critical nursing action: Recognizing Acute Abdomen in the neonate

Rigid boardlike abdomen Inability to palpate abdominal organs Indicators of pain (continuous crying, facial changes, or gross motor movements)

List at least 4 actions to assess the neonates transition to extrauterine life:

Temperature assessment Bathing newborn Nail care and umbilical cord Clothing Diapering Fostering attachment

Clinical alert: Bowel sounds in the scrotum

To confirm that no bowel is entrapped in the scrotum, the nurse carefully auscultates the scrotum for bowel sounds. If bowel sounds are present, immediate assistance must be obtained. This is a medical emergency

Assessment of the Integumentary System:

Wearing gloves, the nurse examines the neonates skin,scalp,and body hair, and nails for color, texture, distributions, disruptions, eruptions, and birthmarks. Important to do assessment in a well lit room Infant's skin should be pink, a finding that indicates adequate peripheral cardiac perfusion. Acrocyanosis, a bluish discoloration to the hands and feet is a normal condition related to vasomotor instability and poor peripheral circulation. **To differentiate between acrocyanosis and true cyanosis, the nurse can vigorously rub the sole of the neonates foot. If the sole turns pink, the diagnosis is acrocyanosis. If the sole remains blue, it is true cyanosis. Also, acrocyanosis disappears when the baby cries. True cyanosis produces a bluish coloration and pallor (paleness) of the lips and on the area around the mouth. ** Plethora-a deep purplish color related to an increased number of circulating red blood cells Petechiae- pinpoint hemorrhagic areas **Infants born with a nuchal cord (umbilical cord around the neck) or those who assumed a face presentation commonly exhibit bruises or petechiae on the head, neck, and face. If extensive bruising is present, the infant's bilirubin levels may be elevated** **Presence of petechiae scattered throughout the infant's body could be an underlying problem such as a low-platelet count or infection. ** Infants skin should feel smooth and soft. Lanugo (fine, downy hair) may be noted on the neonate's back, shoulders, and head, and vernix caseosa may be present in the axillary and genital areas. Posterm infant, the skin is tough and leathery with cracking and peeling. Often, infants are born with pustular melanosis (condition in which small pustules are formed prior to delivery. **Milia- small white papules or sebaceous cysts on the infants face that resembles pimples. ** Erythema toxicum- a transient rash that covers the face and chest with spread to the entire body, is the most common normal skin eruption in term neonates. **Mongolian spots- areas that appear gray, dark, blue or purple and are most commonly located on the back and buttocks, although they may be found on the shoulders, wrists, forearms, and ankles. (Usually found in Latin American, Asian, Mediterranean, African-American babies). Nurse must document Mongolian spots.**

Critical Nursing Action: Recognizing an ophthalmic emergency in the infant:

When using an ophthalmoscope to examine an infant's eyes, the nurse notes the following finding: Right eye: red reflex present. Left eye: Red reflex absent. Significance of this event: Absence of the red reflex indicates an interference with the transmission of light to the retina. This finding is an ophthalmic emergency that requires immediate medical attention because optic nerve suppression from obstructed light pathways may result in permanent blindness. Must notify HCP.