Newborn Care and Assessment

Neonate - Newborn

• Neonate is defined as the first 28 days after birth.
• Physical assessment is performed on neonates.

Physical Assessment

• Apgar score is an evaluation tool.
• It's performed at 1 minute, 5 minutes, and 10 minutes (if needed, if the 5-minute score is less than 7).
• The Apgar score assesses five signs of adaptation: color, heart rate (pulse), reflex irritability (grimace), muscle tone (activity), and respiratory effort (respiration).
• The Apgar score does not drive interventions.

Patient Safety

• Place matching identification bands on the baby, parents, and chart.
• Match ID bands if the baby leaves the room and immediately upon return.
• Verify (and record) band numbers upon discharge.

Newborn Medications

• Erythromycin ointment is given before injections, using a single-use tube inside/on top of the lower conjunctiva
• Vitamin K injection promotes blood clotting.
• Babies cannot be circumcised if vitamin K is declined due to risk of bleeding.
• Hepatitis B vaccine is the first vaccination in the series.
• The shot is done in the opposite leg from the vitamin K injection.

Assessment...expected findings for a Full-term newborn

• Respirations: 30-60 breaths per minute, no retractions or grunting.
• Apical pulse: 120-160 beats per minute.
• Temperature: 97.7°F–99.3°F (36.5°C-37.4°C).
• Skin color: Pink, or pink body with blue extremities.
• Umbilical cord: Contains two arteries and one vein.
• Gestational age: >37 completed weeks.
• Weight: 2,500-4,300 grams.
• Length: 45-54 cm.
• Blood glucose: = 40 mg/dL (but refer to facility guidelines) - done within one hour of birth.

Weigh and measure

• Weigh infant upon delivery.
• Measure length and head circumference.
• Take axillary vital temperature.
• Assess vital signs: heart rate and respiratory rate/quality/effort.

Growth Chart

• The horizontal axis represents gestational age (in weeks).
• The vertical axis represents birth weight (in grams).
• The chart shows intersection between weight and gestational age.
• LGA (large for gestational age), SGA (small for gestational age) can be indicated based on chart.

Weight and Length

• During the first week of life, neonates experience weight loss of 10-15%.
• Preterm infants regain their birth weight slower than full-term infants.
• Average weight gain is 1-3% of body weight per day.
• Pre-Term infants average 0.69-0.75 cm/week.

Calculations

• Calculate weight loss percentage: (birthweight - current weight) / birthweight x 100

Potential Findings

• Conduct a head-to-toe assessment of the newborn.
• Record and report any variances to the provider.
• Remain supportive when communicating potential issues with parents, and watch facial expressions.

Head to Toe Assessment (Durham/Chapman)

• Head and skull: May be asymmetrical.
• Molding: Caput succedaneum (soft, boggy, irregular margins).
• Cephalohematoma (firm, unilateral or bilateral bump, potentially bleeding).
• Palpate fontanels: Anterior and posterior should be soft and flat.
• Skull structure: Six soft plates separated by sutures, which may be overriding, approximated, or separated.

Face

• Symmetry and skin blemishes: Note location, color, any deformities.
• Eyes: Note location, color, any deformities.
• Nose: Both nares patent, bridge of nose intact.
• Mouth: Note lips, gums, palate, tongue, check reflexes (sucking, gag, rooting).
• Ears: Check for canals, position, abnormal indentations or skin tags.
• Chin: Assess for appropriate size.

Integumentary

• Skin color based on ethnicity: Note skin color, should be appropriate for ethnicity.
• Blemishes: Note any blemishes.
• Bruising: Note any bruising.
• Lanugo: Soft, fine hair covering the newborn.
• Vernix caseosa: Creamy protective coating on the skin.
• Mongolian spots: Congenital dermal melanocytosis.
• Birthmarks: Note and classify birthmarks (e.g., nevus flammeus, nevus simplex).

Neck and Chest

• Clavicles: Palpate (intact, no crepitus).
• Chest: Observe shape and position of nipples, presence of Pectus excavatum or Pectus carinatum.
• Respiratory effort: Observe for retractions.
• Lung sounds: Auscultate, count respiratory rate, listen for adventitious sounds.
• Heart sounds: Auscultate for rate and regularity; note any adventitious sounds.

Abdomen to Diaper Area

• Bowel sounds: Auscultate all four quadrants.
• Palpate abdomen.
• Umbilical stump: 3 vessels (2 arteries and 1 vein); Inspect for signs of infection.
• Diaper area: Assess female labia majora, male urethra and testes location, if genitalia not clear, note ambiguous condition. Check for patency of anus.

Back

• Spine: Sit baby up with head leaning slightly forward; observe the spine looking for any sacral dimples, and assess for protruding hair.
• The provider may order an ultrasound to determine if there is a neural tube defect.
• Spine should be straight.
• Look for sacral dimples.

Upper Extremities

• Ensure equal and bilateral movement of arms.
• Fractured clavicle: May affect arm movement.
• Shoulder dystocia: Can lead to a fractured clavicle.
• Moro reflex, Palmar grasp reflex, Palmar crease, Count fingers, Look between fingers, Webbing (may be present).

Lower Extremities

• Check femoral pulses bilaterally.
• Ensure equal and bilateral movement of legs.
• Ortolani test: For hip dysplasia.
• Plantar grasp reflex, Babinski reflex, Count toes, Look between toes, Webbing (may be present).

Neurological

• Assess reflexes (table 15-5 Durham/Chapman).
• Primitive responses based on gestational age.
• Absence of reflexes may warrant additional testing.
• Some reflexes only occur during certain stages of development.
• Assess tone: Hypertonia (jitteriness) or hypotonia may indicate a need for further assessment.

Reflexes

• Palmar grasp: Infant curls fingers around an object.
• Plantar grasp: Infant curls toes around an object placed at the sole of the foot.
• Rooting and sucking reflex: Stroke cheek/mouth, turn toward source, open mouth, and suck.
• Tonic neck (fencing reflex): Supine position, extend arm and leg toward head and turn, flexing opposite arm/leg.
• Moro reflex: Lifting head, extending both arms (and legs).
• Babinski reflex: Stroke plantar surface of foot, toes extend and curl.

Ballard Gestational Age Assessment Tool

• This tool assesses neuromuscular and physical maturity to determine gestational age (useful when the LMP is unknown).

Pain Assessment

• Babies can exhibit pain in different ways.
• Behavioral signs (e.g., crying, agitation, grimacing, guarding).
• Physiological signs (e.g., increased respiratory rate, increased heart rate, increased blood pressure).
• Premature babies may respond differently (e.g. apnea, drop in oxygen saturation, bradycardia).
• Different types of pain scales exist for assessment.

NIPS (Neonatal Infant Pain Scale)

• Used for assessing pain in newborns.

NPASS (Neonatal Pain, Agitation & Sedation Scale)

• Used to assess pain, agitation, and sedation in newborns.

Metabolic Screen

• Heel stick blood draw at 24 hours, followed by a follow up appointment.
• Screens for inborn errors of metabolism to detect enzyme deficiencies early on.

Hearing Screen

• Non-invasive Auditory Brainstem Response (ABR) is used to measure the hearing nerve's response to sound.
• Pass/Fail (can retest once, then referred to audiology for testing)

Critical Congenital Heart Defect (CCHD) Screen

• Non-invasive pulse oximetry is performed on the right hand (pre-ductal) and other hand or either foot (post-ductal) to screen for critical congenital heart defects (CCHD).
• Differences in pulse oximetry readings may indicate a cardiac issue requiring further screening.

Bilirubin

• Typically transcutaneous (non-invasive probe on skin) done 24 hours after birth.
• Repeat/re-check at baby's first discharge visit, with a follow up blood test if required.

Glucose Levels (Heel stick)

• Keep babies warm, since cold stress can deplete glucose levels.
• Neonates should eat within the first hour after birth. -Breastfeeding is best; mother may require assistance.
• Milk isn't always available; colostrum is the first milk and has higher concentrations of glucose.
• Some babies need glucose levels checked until levels are stable to prevent further glucose issues; very low levels may require oral glucose and/or admission to the NICU.

This quiz covers essential concepts related to newborn care, including the definition of a neonate, physical assessment using the Apgar score, and important safety protocols for patient identification. Additionally, it addresses key medications administered to newborns. Test your knowledge on these crucial aspects of neonatal health!