Week 9: Newborn Care PDF

WEEK 9: NEWBORN CARE NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. PROFILE OF A NEWBORN days; a formula-fed i...

WEEK 9: NEWBORN CARE NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. PROFILE OF A NEWBORN days; a formula-fed infant accomplishes this gain It is not unusual to hear the comment “all newborns within 7 days. After this, a newborn begins to gain look alike” from people viewing a nursery full of about 2 lb per month (6 to 8 oz per week) for the babies. In actuality, every child is born with first 6 months of life. Length individual physical and personality characteristics The average birth length (50th percentile) of a that make him or her unique right from the start. mature female neonate is 53 cm (20.9 in). For mature males, the average birth length is 54 cm I. Vital Statistics (21.3 in). The lower limit of normal length is Vital statistics measured in a newborn are arbitrarily set at 46 cm (18 in). Although rare, babies weight, length, and head and chest with lengths as great as 57.5 cm (24 in) have been circumference. Be sure all health care reported. providers involved with newborns are aware of safety issues specific to newborn care when taking these measurements such as not leaving a newborn unattended on a bed or scale. Weight The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. The weight in relation to the gestational age should be plotted on a standard neonatal graph, this way helps identify newborns who are at risk because of their small size. This information also separates those who are small for their gestational age (newborns who have suffered intrauterine growth restriction) from preterm infants Head Circumference (infants who are healthy but small only because In a mature newborn, the head circumference is they were born early). usually 34 to 35 cm (13.5 to 14 in). A mature Plotting weight in conjunction with height and head newborn with a head circumference greater than 37 circumference is also helpful because it highlights cm (14.8 in) or less than 33 cm (13.2 in) should be disproportionate measurements. For example, a carefully assessed for neurologic involvement, newborn who falls within the 50th percentile for although occasionally a well newborn falls within height and weight but whose head circumference is these limits. in the 90th percentile may have abnormal head Head circumference is measured with a tape growth. A newborn who is in the 50th percentile for measure drawn across the center of the forehead weight and head circumference but in the 3rd and around the most prominent portion of the percentile for height may have a growth problem. posterior head. The average birth weight (50th percentile) for a white, mature female newborn in the United States is 3.4 kg (7.5 lb); for a white, mature male newborn, it is 3.5 kg (7.7 lb). Newborns of other races weigh approximately 0.5 lb less. The arbitrary lower limit of normal for all races is 2.5 kg (5.5 lb). Birth weight exceeding 4.7 kg (10 lb) is unusual, but weights as high as 7.7 kg (17 lb) have been documented. If a newborn weighs more than 4.7 kg, the baby is said to be macrosomic and a maternal illness, such as diabetes mellitus, must be suspected (Kwik et al., 2007). Second-born children usually weigh more than first-born. Birth weight continues to increase with each succeeding child in Chest Circumference a family. The chest circumference in a term newborn is about After this initial loss of weight, a newborn has 1 day 2 cm (0.75 to 1 in) less than the head of stable weight, then begins to gain weight. The circumference. This is measured at the level of the breastfed newborn recaptures birth weight within 10 nipples. If a large amount of breast tissue or edema  of breasts is present, this measurement will not be accurate until the edema has subsided. Pulse The heart rate of a fetus in utero averages 120 to 160 beats per minute (bpm). Immediately after birth, as the newborn struggles to initiate respirations, the heart rate may be as rapid as 180 bpm. Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to an average of 120 to 140 bpm. The heart rate of a newborn often remains slightly irregular because of immaturity of the cardiac regulatory center in the medulla. Transient murmurs may result from the incomplete closure of fetal circulation shunts. During crying, the rate may rise again to 180 bpm. In addition, heart rate can II. Vital Signs decrease during sleep, ranging from 90 to 110 bpm. You should be able to palpate brachial and femoral Vital sign measurements begin to change pulses in a newborn, but the radial and temporal from those present in intrauterine life at the pulses are more difficult to palpate with any degree moment of birth of accuracy. Therefore, a newborn’s heart rate is always determined by listening for an apical Temperature heartbeat for a full minute, rather than assessing a The temperature of newborns is about 99° F (37.2° C) at pulse in an extremity. birth because they have been confined in an internal body organ. The temperature falls almost immediately to below Respiration normal because of heat loss and immature temperature The respiratory rate of a newborn in the first few minutes of regulating mechanisms. The temperature of birthing rooms, life may be as high as 80 breaths per minute. As respiratory approximately 68° to 72° F (21° to 22° C), can add to this activity is established and maintained, this rate settles to an loss of heat. average of 30 to 60 breaths per minute when the newborn A newborn loses heat easily because of difficulty is at rest. Respiratory depth, rate, and rhythm are conserving heat under any circumstance. Insulation, likely to be irregular, and short periods of apnea (without an efficient means of conserving heat in adults, is cyanosis) which last less than 15 seconds, sometimes called not effective in newborns because they have little periodic respirations, are normal. subcutaneous fat to provide insulation. Shivering, a Respiratory rate can be observed most easily by means of increasing metabolism and thereby watching the movement of a newborn’s abdomen, providing heat in adults, is rarely seen in newborns. because breathing primarily involves the use of the Newborns can conserve heat by constricting blood diaphragm and abdominal muscles. vessels and moving blood away from the skin. Brown fat, a special tissue found in mature Blood Pressure newborns, apparently helps to conserve or produce The blood pressure of a newborn is approximately 80/46 mm body heat by increasing metabolism. The greatest Hg at birth. By the 10th day, it rises to about 100/50 mm Hg. amounts of brown fat are found in the interscapular Because measurement of blood pressure in a newborn is region, thorax, and perirenal area. Brown fat is somewhat inaccurate, it is not routinely measured unless a thought to aid in controlling newborn temperature cardiac anomaly is suspected. For an accurate reading, the similar to temperature control in a hibernating cuff width used must be no more than two thirds the length of animal. In later life, it may influence the proportion the upper arm or thigh. Blood pressure tends to increase with of body fat retained. crying (and a newborn cries when disturbed and manipulated Newborns exposed to cool air tend to kick and cry by such procedures as taking blood pressure). A Doppler to increase their metabolic rate and produce more method may be used to take blood pressure. heat. This reaction, however, also increases their need for oxygen and their respiratory rate III. Physiologic Function increases. An immature newborn with poor lung development has trouble making such an Cardiovascular System adjustment. Changes in the cardiovascular system are necessary after Drying and wrapping newborns and placing them birth because now the lungs must oxygenate the blood that in warmed cribs, or drying them and placing them was formerly oxygenated by the placenta. When the cord is under a radiant heat source, are excellent clamped, a neonate is forced to take in oxygen through the mechanical measures to help conserve heat. In lungs. As the lungs inflate for the first time, pressure addition, placing a newborn against the mother’s decreases in the pulmonary artery (the artery leading from skin and then covering the newborn with a blanket the heart to the lungs). This decrease in pressure plays a helps to transfer heat from the mother to the role in promoting closure of the ductus arteriosus, a fetal newborn; this is termed skin-to-skin care. shunt. As pressure increases in the left side of the heart from increased blood volume, the foramen ovale between the BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 2 two atria closes because of the pressure against the lip of The first stool of a newborn is usually passed within the structure (permanent closure does not occur for weeks). 24 hours after birth. It consists of meconium, a With the remaining fetal circulatory structures (umbilical vein, sticky, tarlike, blackish-green, odorless material two umbilical arteries, and ductus venosus) no longer formed from mucus, vernix, lanugo, hormones, and receiving blood, the blood within them clots, and the vessels carbohydrates that accumulated during intrauterine atrophy over the next few weeks. life. If a newborn does not pass a meconium stool The hematocrit is between 45% and 50%. A by 24 to 48 hours after birth, the possibility of some newborn also has an elevated red blood cell count, factor such as meconium ileus, imperforate anus, or about 6 million cells per cubic millimeter. Once volvulus should be suspected. proper lung oxygenation has been established, the About the second or third day of life, newborn stool need for the high red cell count diminishes. changes in color and consistency, becoming green Therefore, within a matter of days, a newborn’s red and loose. This is termed transitional stool, and it cells begin to deteriorate. Bilirubin is a byproduct of may resemble diarrhea to the untrained eye. By the the breakdown of red blood cells. An indirect fourth day of life, breastfed babies pass three or bilirubin level at birth is 1 to 4 mg/100 mL. Any four light yellow stools per day. They are increase over this amount reflects the release of sweet-smelling, because breast milk is high in lactic bilirubin as excessive red blood cells begin their acid, which reduces the amount of putrefactive breakdown. organisms in the stool. A newborn who receives A newborn has an equally high white blood cell formula usually passes two or three bright yellow count at birth, about 15,000 to 30,000 cells/mm3. stools a day. These have a slightly more noticeable Values as high as 40,000 cells/mm3 may be seen if odor, compared with the stools of breastfed babies. the birth was stressful. Urinary System Respiratory System The average newborn voids within 24 hours after birth. A A first breath is a major undertaking because it requires a newborn who does not take in much fluid for the first 24 tremendous amount of pressure (about 40 to 70 cm H2O). It hours may void later than this, but the 24-hour point is a is initiated by a combination of cold receptors; a lowered good general rule. Newborns who do not void within this time partial pressure of oxygen (PO2), which falls from 80 to as should be examined for the possibility of urethral stenosis or low as 15 mm Hg before a first breath; and an increased absent kidneys or ureters. partial carbon dioxide pressure (PCO2), which rises as high A single voiding in a newborn is only about 15 mL as 70 mm Hg before a first breath. and may be easily missed in a thick diaper. Specific All newborns have some fluid in their lungs from gravity ranges from 1.008 to 1.010. The daily intrauterine life that will ease the surface tension on urinary output for the first 1 or 2 days is about 30 to alveolar walls and allow alveoli to inflate more easily 60 mL total. By week 1, total daily volume rises to than if the lung walls were dry. About a third of this about 300 mL. The first voiding may be pink or fluid is forced out of the lungs by the pressure of dusky because of uric acid crystals that were vaginal birth. Additional fluid is quickly absorbed by formed in the bladder in utero; this is an innocent lung blood vessels and lymphatics after the first finding. breath. Once the alveoli have been inflated with a first Immune System breath, breathing becomes much easier for a baby, Because they have difficulty forming antibodies against requiring only about 6 to 8 cm H2O pressure. Within invading antigens until about 2 months of age, newborns are 10 minutes after birth, most newborns have prone to infection. This inability to form antibodies is the established a good residual volume. reason that most immunizations against childhood diseases A newborn who has difficulty establishing are not given to infants younger than 2 months of age. respirations at birth should be examined closely in Newborns do have some immunologic protection, because the postpartal period for a cardiac murmur or other they are born with passive antibodies (immunoglobulin G) indication that he or she still has patent fetal cardiac from their mother that crossed the placenta. In most structures, especially a patent ductus arteriosus. instances, these include antibodies against poliomyelitis, measles, diphtheria, pertussis, chickenpox, rubella, and Gastrointestinal System tetanus. Newborns are routinely administered hepatitis B Although the gastrointestinal tract is usually sterile at birth, vaccine during the first 12 hours after birth to protect against bacteria may be cultured from the intestinal tract in most this disease. babies within 5 hours after birth and from all babies at 24 hours of life. Most of these bacteria enter the tract through Neuromuscular System the newborn’s mouth from airborne sources. Others may Mature newborns demonstrate neuromuscular function by come from vaginal secretions at birth, from hospital bedding, moving their extremities, attempting to control head and from contact at the breast. Accumulation of bacteria in movement, exhibiting a strong cry, and demonstrating the gastrointestinal tract is necessary for digestion and for newborn reflexes. Limpness or total absence of a muscular the synthesis of vitamin K. response to manipulation is never normal and suggests narcosis, shock, or cerebral injury. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 3 Newborn reflexes can be tested with consistency by using Swallowing Reflex simple maneuvers. The swallowing reflex in a newborn is the same as in the adult. Food that reaches the posterior portion Blink Reflex of the tongue is automatically swallowed. Gag, A blink reflex in a newborn serves the same cough, and sneeze reflexes also are present in purpose as it does in an adult—to protect the eye newborns to maintain a clear airway in the event from any object coming near it by rapid eyelid that normal swallowing does not keep the pharynx closure. It may be elicited by shining a strong light free of obstructing mucus. such as a flashlight or an otoscope light on an eye. A sudden movement toward the eye sometimes can Extrusion Reflex elicit the blink reflex. A newborn extrudes any substance that is placed on the anterior portion of the tongue. This protective reflex prevents the swallowing of inedible substances. It disappears at about 4 months of age. Until then, the infant may seem to be spitting out or refusing solid food placed in the mouth. Rooting Reflex If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the head in that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborn’s cheek, the reflex makes the baby turn toward the breast. The reflex Palmar Grasp Reflex disappears at about the sixth week of life. At about Newborns grasp an object placed in their palm by this time, newborn eyes focus steadily, so food closing their fingers on it. Mature newborns grasp source can be seen, and the reflex is no longer so strongly that they can be raised from a supine needed. position and suspended momentarily from an examiner’s fingers. This reflex disappears at about 6 weeks to 3 months of age. A baby begins to grasp meaningfully at about 3 months of age. Sucking Reflex When a newborn’s lips are touched, the baby makes a sucking motion. The reflex helps a newborn find food: when the newborn’s lips touch Step (Walk)-in-Place Reflex. the mother’s breast or a bottle, the baby sucks and Newborns who are held in a vertical position with so takes in food. The sucking reflex begins to their feet touching a hard surface will take a few diminish at about 6 months of age. It disappears quick, alternating steps. This reflex disappears by 3 immediately flex disappears at about the sixth week months of age. By 4 months, babies can bear a of life. good portion of their weight unhindered by this reflex. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 4 Plantar Grasp Reflex Babinski Reflex When an object touches the sole of a newborn’s When the sole of the foot is stroked in an inverted foot at the base of the toes, the toes grasp in the “J” curve from the heel upward, a newborn fans the same manner as do the fingers. This reflex toes (positive Babinski sign) (Fig. 18.8). This is in disappears at about 8 to 9 months of age in contrast to the adult, who flexes the toes. This preparation for walking. However, it may be present reaction occurs because nervous system during sleep for a longer period. development is immature. It remains positive (toes fan) until at least 3 months of age, when it is supplanted by the downturning or adult flexion response. Tonic Neck Reflex When newborns lie on their backs, their heads usually turn to one side or the other. The arm and the leg on the side toward which the head turns extend, and the opposite arm and leg contract. If you turn a newborn’s head to the opposite side, he Magnet Reflex or she will often change the extension and If pressure is applied to the soles of the feet of a contraction of legs and arms accordingly. This is newborn lying in a supine position, he or she also called a boxer or fencing reflex, because the pushes back against the pressure. This and the two position simulates that of someone preparing to box following reflexes are tests of spinal cord integrity. or fence. It may signify handedness. The reflex disappears between the second and third months of life. Crossed Extension Reflex If one leg of a newborn lying supine is extended and Moro Reflex the sole of that foot is irritated by being rubbed with A Moro (startle) reflex can be initiated by startling a a sharp object, such as a thumbnail, the infant newborn with a loud noise or by jarring the bassinet. raises the other leg and extends it, as if trying to The most accurate method of eliciting the reflex is push away the hand irritating the first leg. to hold newborns in a supine position and allow their heads to drop backward about 1 inch. In response to this sudden head movement, they abduct and extend their arms and legs. Their fingers assume a typical “C” position. It is strong for the first 8 weeks of life and then fades by the end of the fourth or fifth month, at the same time an infant can roll away from danger. Trunk Incurvation Reflex When newborns lie in a prone position and are touched along the paravertebral area by a probing finger, they flex their trunk and swing their pelvis toward the touch. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 5  ability to respond to odors can be used to document alertness. IV. Appearance of a Newborn 1. Skin A. Color Most term newborns have a ruddy Landau Reflex complexion because of the increased A newborn who is held in a prone position with a concentration of red blood cells in blood hand underneath, supporting the trunk, should vessels and a decrease in the amount of demonstrate some muscle tone. Babies may not be subcutaneous fat, which makes the blood able to lift their head or arch their back in this vessels more visible. This ruddiness fades position (as they will at 3 months of age), but slightly over the first month. Infants with neither should they sag into an inverted “U” poor central nervous system control may position. The latter response indicates extremely appear pale and cyanotic. A gray color in poor muscle tone, the cause of which should be newborns generally indicates infection. investigated. Cyanosis. Generalized mottling of the skin is common. A newborn’s lips, hands, and feet are likely to appear blue from immature peripheral circulation. Acrocyanosis (blueness of hands and feet) is so prominent in some newborns that it appears as if some stricture were cutting off circulation, with usual skin color on one Vision side and blue on the other. Acrocyanosis is Newborns see as soon as they are born and a normal phenomenon in the first 24 to 48 possibly have been “seeing” light and dark in utero hours after birth; however, central for the last few months of pregnancy, as the uterus cyanosis, or cyanosis of the trunk, is and the abdominal wall were stretched thin. always a cause for concern. Central Newborns demonstrate sight at birth by blinking at a cyanosis indicates decreased oxygenation. strong light (blink reflex) or by following a bright light It may be the result of a temporary or toy a short distance with their eyes. respiratory obstruction or an underlying disease state Touch The sense of touch is also well developed at birth. Hyperbilirubinemia Newborns demonstrate this by quieting at a Hyperbilirubinemia leads to jaundice, or yellowing of soothing touch and by sucking and rooting reflexes, the skin (Beachy, 2007). This occurs on the second which are elicited by touch. They also react to or third day of life in about 50% of all newborns, as painful stimuli. a result of a breakdown of fetal red blood cells (physiologic jaundice). The infant’s skin and the Taste sclera of the eyes appear noticeably yellow. This A newborn has the ability to discriminate taste, happens because the high red blood cell count built because taste buds are developed and functioning up in utero is destroyed, and heme and globin are even before birth. A fetus in utero, for example, will released. swallow amniotic fluid more rapidly than usual if Many newborns have such immature liver function glucose is added to sweeten its taste. The that indirect bilirubin cannot be converted to the swallowing decreases if a bitter flavor is added. A direct form; it therefore remains indirect. As long as newborn turns away from a bitter taste such as salt the buildup of indirect bilirubin remains in the but readily accepts the sweet taste of milk or circulatory system, the red coloring of the blood glucose water. cells covers the yellow tint of the bilirubin. After the level of this indirect bilirubin has risen to more than Smell 7 mg/100 mL, however, bilirubin permeates the The sense of smell is present in newborns as soon tissue outside the circulatory system and causes as the nose is clear of lung and amniotic fluid. the infant to appear jaundiced. Newborns turn toward their mothers’ breast partly Observe infants who are prone to extensive bruising out of recognition of the smell of breast milk and (large, breech, or immature babies) carefully for partly as a manifestation of the rooting reflex. Their jaundice, because bruising leads to hemorrhage of blood into the subcutaneous tissue or skin. A cephalhematoma is a collection of blood under the BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 6  periosteum of the skull bone. As the bruising in d. low iron stores caused by poor maternal these locations heals and the red blood cells are nutrition during pregnancy, or hemolyzed, additional indirect bilirubin is released e. blood incompatibility in which a large and can be another cause of jaundice (Nicholson, number of red blood cells were hemolyzed 2007). in utero. It also may be the result of If intestinal obstruction is present and stool cannot internal bleeding. A baby who appears be evacuated, intestinal flora may break down bile pale should be watched closely for signs of into its basic components, leading to the release of blood in stool or vomitus. indirect bilirubin into the bloodstream again. Early feeding of newborns promotes intestinal movement Harlequin Sign and excretion of meconium and helps prevent Occasionally, because of immature circulation, a indirect bilirubin buildup from this source. newborn who has been lying on his or her side The level of jaundice in newborns may be judged appears red on the dependent side of the body and grossly by estimating the extent to which it has pale on the upper side, as if a line had been drawn progressed on the surface of the infant’s body, as it down the center of the body. This is a transient is noticed first in the head and then spreads to the phenomenon; although startling, it is of no clinical rest of the body. significance. The odd coloring fades immediately if Treatment for physiologic jaundice or the routine the infant’s position is changed or the baby kicks or rise in bilirubin in newborns is rarely necessary, cries vigorously. except for measures such as early feeding to speed passage of feces through the intestine and prevent reabsorption of bilirubin from the bowel. Above-normal indirect bilirubin levels are potentially dangerous because, if enough indirect bilirubin (about 20 mg/100 mL) leaves the bloodstream, it can interfere with the chemical synthesis of brain cells, resulting in permanent cell damage, a condition termed kernicterus. If this occurs, B. Birthmarks permanent neurologic damage, including cognitive It is important to be able to differentiate the various types of challenge, may result. hemangiomas that occur, so that you neither give false There is no set level at which indirect serum reassurance to parents nor worry them unnecessarily about bilirubin requires treatment, because other factors, these lesions. such as age, maturity, and breastfeeding status, affect this determination. If the level rises to more Hemangiomas than 10 to 12 mg/100 mL, treatment is usually The hemangiomas are vascular tumors of the skin. Three considered. Phototherapy (exposure of the infant to types occur. light to initiate maturation of liver enzymes) is a a. Nevus Flammeus - is a macular purple or dark-red common therapy. If this is necessary, the incubator lesion (sometimes called a port wine stain because and light source can be moved to the mother’s of its deep color) that is present at birth. These room so that the mother is not separated from her lesions typically appear on the face, although they baby. Some infants need continued therapy after are often found on the thighs as well. Those above discharge and receive phototherapy at home (Mills the bridge of the nose tend to fade; the others are & Tudehope, 2009). less likely to fade. Because they are level with the Compared with formula-fed babies, a small skin surface (macular), they can be covered by a proportion of breastfed babies may have more cosmetic preparation later in life or removed by difficulty converting indirect bilirubin to direct laser therapy, although lesions may reappear after bilirubin, because breast milk contains pregnanediol treatment (Berger, 2009). (a metabolite of progesterone), which depresses the action of glucuronyl transferase. However, breastfeeding alone rarely causes enough jaundice to warrant therapy (Thilo & Rosenberg, 2008). Pallor Pallor in newborns is usually the result of anemia. This may be caused by a. excessive blood loss when the cord was cut, Nevus flammeus lesions also occur as lighter, pink patches b. inadequate flow of blood from the cord into at the nape of the neck, known as stork’s beak marks or the infant at birth, telangiectasia. These do not fade, but they are covered by c. fetal–maternal transfusion, the hairline and therefore are of no consequence. They occur more often in females than in males. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 7  Mongolian spots Mongolian spots are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs. They tend to occur in children of Asian, southern European, or African ethnicity (Thilo & Rosenberg, 2008). They disappear by school age without treatment. Be sure to inform parents that these are not bruises; otherwise, they may worry their baby sustained a birth injury. b. Strawberry hemangioma - refers to elevated areas formed by immature capillaries and endothelial cells. Most are present at birth in the term neonate, although they may appear up to 2 weeks after birth. Typically, they are not present in the preterm infant because of the immaturity of the epidermis. Formation is associated with the high estrogen levels of pregnancy. They may continue to enlarge from their original size up to 1 year of age. After the first year, they tend to be absorbed and shrink in size. By the time the child is 7 years old, 50% to C. Vernix Caseosa 75% of these lesions have disappeared. Vernix caseosa is a white, cream cheese–like substance that serves as a skin lubricant in utero. Usually, it is noticeable on a newborn's skin, at least in the skin folds, at birth. Document the color of vernix, because it takes on the color of the amniotic fluid. For example, a yellow vernix implies that the amniotic fluid was yellow from bilirubin; green vernix indicates that meconium was present in the amniotic fluid. Until the first bath, when vernix is A child may be 10 years old before the absorption is washed away, handle newborns with gloves to complete. Application of hydrocortisone ointment may speed protect yourself from exposure to this body fluid. the disappearance of these lesions by interfering with the Never use harsh rubbing to wash away vernix. A binding of estrogen to its receptor sites. newborn’s skin is tender, and breaks in the skin caused by too vigorous attempts at removal may c. Cavernous hemangiomas - are dilated vascular open portals of entry for bacteria. spaces. They are usually raised and resemble a strawberry hemangioma in appearance. However, they do not disappear with time as do strawberry hemangiomas. Such lesions can be removed surgically. Steroids, interferon-alfa-2a, or vincristine can be used to reduce these lesions in size, although their use must be weighed in light of side effects (Edmonds, 2008). Children who have a skin lesion may have additional ones on internal organs. Blows to the abdomen, such as those from childhood games, can cause bleeding from an D. Lanugo internal hemangioma. For this reason, children with Lanugo is the fine, downy hair that covers a cavernous hemangiomas usually have their newborn’s shoulders, back, and upper arms. It may hematocrit levels assessed at health maintenance also be found on the forehead and ears. A baby visits, to evaluate for possible internal blood loss. born between 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks’ gestational age. Postmature infants (more than 42 weeks of gestation) rarely have lanugo. Lanugo is rubbed away by the friction of bedding and clothes against the newborn’s skin. By 2 weeks of age, it has disappeared. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 8  H. Skin Turgor Newborn skin should feel resilient if the underlying tissue is well hydrated. If a fold of the skin is grasped between the thumb and fingers, it should feel elastic. When it is released, it should fall back to form a smooth surface. If severe dehydration is present, the skin will not smooth out again but will remain in an elevated ridge. Poor turgor is seen in newborns who suffered malnutrition in utero, who have difficulty sucking at birth, or who have certain E. Desquamation metabolic disorders such as adrenocortical Within 24 hours after birth, the skin of most insufficiency. newborns has become extremely dry. The dryness is particularly evident on the palms of the hands and 2. Head soles of the feet. This results in areas of peeling A newborn’s head appears disproportionately large similar to those caused by sunburn. This is normal, because it is about one fourth of the total body however, and needs no treatment. Parents may length; in an adult, a head is one eighth of total apply hand lotion to prevent excessive dryness if height. The forehead of a newborn is large and they wish. prominent. The chin appears to be receding, and it quivers easily if an infant is startled or cries. F. Milia Well-nourished newborns have full-bodied hair; All newborn sebaceous glands are immature. At poorly nourished and preterm infants have thin, least one pinpoint white papule (a plugged or lifeless hair. If internal fetal monitoring was used unopened sebaceous gland) can be found on the during labor, a newborn may exhibit a pinpoint ulcer cheek or across the bridge of the nose of almost at the point where the monitor was attached. every newborn. Such lesions, termed milia, disappear by 2 to 4 weeks of age, as the sebaceous Fontanelles glands mature and drain. Teach parents to avoid The fontanelles are the spaces or openings where scratching or squeezing the papules, to prevent the skull bones join. The anterior fontanelle is secondary infections. located at the junction of the two parietal bones and the two fused frontal bones. It is diamond shaped and measures 2 to 3 cm (0.8 to 1.2 in) in width and 3 to 4 cm (1.2 to 1.6 in) in length. The posterior fontanelle is located at the junction of the parietal bones and the occipital bone. It is triangular and measures about 1 cm (0.4 in) in length. The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) G. Erythema Toxicum when the infant is held upright. The fontanelle may In most normal mature infants, a newborn rash bulge if the newborn strains to pass a stool or cries called erythema toxicum can be observed. This vigorously or is lying supine. With vigorous crying, a usually appears in the first to fourth day of life but pulse may additionally be seen in the fontanelle. may appear up to 2 weeks of age. It begins with a The anterior fontanelle normally closes at 12 to 18 papule, increases in severity to become erythema months of age. In some newborns, the posterior by the second day, and then disappears by the third fontanelle is so small that it cannot be palpated day. It is sometimes called a flea-bite rash because readily. The posterior fontanelle closes by the end the lesions are so minuscule. One of the chief of the second month. characteristics of the rash is its lack of pattern. It occurs sporadically and unpredictably and may last hours rather than days. It is caused by a newborn’s eosinophils reacting to the environment as the immune system matures. It requires no treatment. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 9 Sutures hours after birth. Although the blood loss is The skull sutures, the separating lines of the skull, negligible, the swelling is usually severe and is well may override at birth because of the extreme outlined as an egg shape. It may be discolored pressure exerted on the head during passage (black and blue) because of the presence of through the birth canal. If the sagittal suture coagulated blood. between the parietal bones overrides, the A cephalhematoma is confined to an individual fontanelles are less perceptible than usual. The bone, so the associated swelling stops at the bone’s overriding subsides in 24 to 48 hours. suture line. It often takes weeks for a Suture lines should never appear widely separated cephalhematoma to be absorbed. It might be in newborns. Wide separation suggests increased supposed that the blood could be aspirated to intracranial pressure because of abnormal brain relieve the condition. However, such a procedure formation, abnormal accumulation of cerebrospinal would introduce the risk of infection and is fluid in the cranium (hydrocephalus), or an unnecessary, because the condition will subside by accumulation of blood from a birth injury such as itself. As the blood captured in the space is broken subdural hemorrhage. Fused suture lines also are down, a great amount of indirect bilirubin may be abnormal; they require radiographic confirmation released, leading to jaundice. and further evaluation, because they will prevent the head from expanding with brain growth. Craniotabes Craniotabes is a localized softening of the cranial Molding bones that is probably caused by pressure of the The part of the infant’s head that engaged the fetal skull against the mother’s pelvic bone in utero. cervix (usually the vertex) molds to fit the cervix It is more common in firstborn infants than in infants contours during labor. After birth, this area appears born later, because of the lower position of the fetal prominent and asymmetric. Molding may be so head in the pelvis during the last 2 weeks of extreme in the baby of a primiparous woman that pregnancy in primiparous women. With craniotabes, the baby’s head appears as a dunce cap. The head the skull is so soft that the pressure of an examining will restore to its normal shape within a few days finger can indent it. The bone returns to its normal after birth. contour after the pressure is removed. The condition corrects itself without treatment after a few Caput Succedaneum months, as the infant takes in calcium in milk. Caput succedaneum is edema of the scalp at the presenting part of the head. It may involve wide areas of the head, or it may resemble a large egg. The edema, which crosses the suture lines, is gradually absorbed and disappears at about the third day of life. It needs no treatment (Nicholson, 2007). 3. Eyes Newborns usually cry tearlessly, because their lacrimal ducts do not fully mature until about 3 months of age. Almost without exception, the irises of the eyes of newborns are gray or blue; the sclera may be blue because of its thinness. Infant eyes assume their permanent color between 3 and 12 Cephalhematoma months of age. To inspect the eyes, lay the newborn A cephalhematoma, a collection of blood between in a supine position and lift the head. This the periosteum of a skull bone and the bone itself, is maneuver causes the baby to open the eyes. A caused by rupture of a periosteal capillary because newborn’s eyes should appear clear, without of the pressure of birth. Swelling usually appears 24 redness or purulent discharge. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 10 4.Ears 7.Neck A newborn’s external ear is not as completely The neck of a newborn is short and often chubby, formed as it will be eventually, so the pinna tends to with creased skin folds. The head should rotate bend easily. In the term newborn, however, the freely on it. If there is rigidity of the neck, congenital pinna should be strong enough to recoil after torticollis, caused by injury to the bending. The level of the top part of the external ear sternocleidomastoid muscle during birth, might be should be on a line drawn from the inner canthus to present. In newborns whose membranes were the outer canthus of the eye and back across the ruptured more than 24 hours before birth, nuchal side of the head. Ears that are set lower than this rigidity suggests meningitis. are found in infants with certain chromosomal The neck of a newborn is not strong enough to abnormalities, particularly trisomy 18 and 13, support the total weight of the head but in a sitting syndromes in which low-set ears and other physical position, a newborn should make a momentary defects are coupled with varying degrees of effort at head control. When lying prone, newborns cognitive challenge. can raise the head slightly, usually enough to lift the A good practice is to test a newborn’s hearing by nose out of mucus or spit-up formula. If they are ringing a bell held about 6 inches from each ear. A pulled into a sitting position from a supine position, hearing infant who is crying will stop momentarily at the head will lag behind considerably. the sound. If quiet, a newborn who can hear will blink the eyes, appear to attend to the sound, and 8. Chest possibly startle. Although this method of testing is The chest in some newborns looks small because not highly accurate, a negative response (lack of the head is large in proportion. It is actually response) is unusual. approximately 2 inches smaller in circumference than and as wide in the anteroposterior diameter as 5.Nose it is across. Not until a child is 2 years of age does A newborn’s nose tends to appear large for the the chest measurement exceed that of the head. face. As the infant grows, the rest of the face grows The clavicles should be straight. A crepitus or actual more than the nose does, and this discrepancy separation on one or the other clavicle may indicate disappears. Test for choanal atresia (blockage at that a fracture occurred during birth and calcium is the rear of the nose) by closing the newborn’s now being deposited at that point. mouth and compressing one naris at a time with Overall, a newborn’s chest should appear your fingers. Note any discomfort or distress while symmetric side to side. Respirations are normally breathing this way. Nasal flaring upon inspiration is rapid (30 to 60 breaths per minute) but not another indication of respiratory distress and should distressed. A supernumerary nipple (usually found be further evaluated. Also record any evidence of below and in line with the normal nipples) may be milia on the nose. present. If so, it may be removed later for cosmetic purposes although this is not necessary. 6. Mouth In both female and male infants, the breasts may be A newborn’s mouth should open evenly when he or engorged. Occasionally, the breasts of newborn she cries. If one side of the mouth moves more than babies secrete a thin, watery fluid popularly termed the other, cranial nerve injury is suggested. A witch’s milk. Engorgement develops in utero as a newborn’s tongue appears large and prominent in result of the influence of the mother’s hormones. As the mouth. Because the tongue is short, the soon as the hormones are cleared from the infant’s frenulum membrane is attached close to the tip of system (about 1 week), the engorgement and any the tongue, creating the impression that the infant is fluid that is present subside. “tongue tied.” Retraction (drawing in of the chest wall with Inspect the palate of a newborn to be sure it is inspiration) should not be present. An infant with intact. Occasionally, one or two small, round, retractions is using such strong force to pull air into glistening, well circumscribed cysts (Epstein’s the respiratory tract that he or she is pulling in the pearls) are present on the palate, a result of extra anterior chest muscle. An abnormal sound, such as calcium that was deposited in utero. Be sure to grunting, suggests respiratory distress syndrome; a inform parents that these pearl-like cysts are high, crowing sound on inspiration suggests stridor insignificant, require no treatment, and will or immature tracheal development. disappear spontaneously within 1 week. Otherwise, a parent may mistake them for thrush, a Candida 9. Abdomen infection, which usually appears on the tongue and The contour of a newborn abdomen looks slightly sides of the cheeks as white or gray patches and protuberant. A scaphoid or sunken appearance may needs therapy with an antifungal drug indicate missing abdominal contents or a (Subramanian et al., 2008). diaphragmatic hernia (bowel positioned in the chest instead of the abdomen). Bowel sounds should be present within 1 hour after birth. The edge of the liver is usually palpable 1 to 2 cm below the right BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 11  costal margin. The edge of the spleen may be artery is too short to allow the testes to palpable 1 to 2 cm below the left costal margin. descend). Tenderness is difficult to determine in a newborn. If ○ Elicit a cremasteric reflex by stroking the it is extreme, however, palpation will cause the internal side of the thigh. As the skin is infant to cry, thrash about, or tense the abdominal stroked, the testis on that side moves muscles to protect the abdomen. perceptibly upward. This is a test for the For the first hour after birth, the stump of the integrity of spinal nerves T8–T10. The umbilical cord appears as a white, gelatinous response may be absent in newborns who structure marked with the blue and red streaks of are younger than 10 days. The penis of the umbilical vein and arteries. When the cord is newborns appears small, approximately 2 first cut, the vessels are counted to be certain that cm long. If it is less than this, the newborn one vein and two arteries are present. should be referred for evaluation by an Inspect the cord clamp to be certain it is secure. endocrinologist. Inspect the tip of the penis After the first hour of life, the cord begins to dry and to see that the urethral opening is at the tip shrink, and it turns brown like the dead end of a of the glans, not on the dorsal surface vine. By the second or third day, it has turned black. (epispadias) or on the ventral surface It breaks free by day 6 to 10, leaving a granulating (hypospadias). area a few centimeters wide that heals during the Female Genitalia following week. ○ The vulva in female newborns may be The base of the cord should appear dry. A moist or swollen because of the effect of maternal odorous cord suggests infection. If present, hormones. Some female newborns have a infection should receive immediate treatment or it mucus vaginal secretion, which is may enter a newborn’s bloodstream and cause sometimes blood-tinged septicemia. (pseudomenstruation). Again, this is To finish the abdominal assessment, elicit an caused by the action of maternal abdominal reflex. Stroking each quadrant of the hormones. The discharge disappears as abdomen will cause the umbilicus to move or “wink” soon as the infant’s system has cleared in that direction. This superficial abdominal reflex is the hormones. The discharge should not a test of spinal nerves T8–T10. The reflex may not be mistaken for an infection or taken as an be demonstrable in newborns until the 10th day of indication that trauma has occurred. life. 11.Back 10. Anogenital The spine of a newborn typically appears flat in the Area Inspect the anus of a newborn to be certain it lumbar and sacral areas. The curves seen in an is present, patent, and not covered by a membrane adult appear only after a child is able to sit and (imperforate anus). Test for anal patency by gently walk. Inspect the base of a newborn’s spine inserting the tip of your gloved and lubricated little carefully to be sure there is no pinpoint opening, finger. Also note the time after birth at which the dimpling, or sinus tract in the skin, which would. infant first passes meconium. If a newborn does not suggest a dermal sinus or spinal bifida occulta. True do so in the first 24 hours, suspect imperforate anus neural tube defects in newborns are greatly or meconium ileus. decreased in incidence because of the recognition Male Genitalia that lack of folic acid during pregnancy leads to ○ The scrotum in most male newborns is these (De Wals et al., 2007). edematous and has rugae (folds in the A newborn normally assumes the position skin). It may be deeply pigmented in maintained in utero, with the back rounded and the African American or dark-skinned arms and legs flexed on the abdomen and chest. A newborns. Make a practice of pressing child who was born in a frank breech position tends your nondominant hand against the to straighten the legs at the knee and bring their inguinal ring before palpating for testes, so feet up next to the face. they do not slip upward and out of the scrotal sac as you palpate. 12. Extremities ○ Both testes should be present in the The arms and legs of a newborn appear short. The scrotum. If one or both testicles are not hands are plump and clenched into fists. Newborn present (cryptorchidism), referral is needed fingernails are soft and smooth, and usually long to establish the extent of the problem. This enough to extend over the fingertips. Test the upper condition could be caused by agenesis extremities for muscle tone by unflexing the arms (absence of an organ), ectopic testes (the for approximately 5 seconds. If tone is good, an arm testes cannot enter the scrotum because should return immediately to its flexed position after the opening to the scrotal sac is closed), or being released. Hold the arms down by the sides undescended testes (the vas deferens or and note their length. The fingertips should reach the proximal thigh. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 12  Unusually short arms may signify achondroplastic dwarfism. Observe for unusual curvature of the little finger, and inspect the palm for a simian crease (a single palmar crease, in contrast to the three creases normally seen in a palm). Although curved fingers and simian creases can occur normally, they are commonly associated with Down syndrome (Elias, ChunHui, & Manchester, 2008). Assess for webbing (syndactyly), extra toes or fingers (polydactyly), or unusual spacing of toes, particularly between the big toes and the others (this finding is present in certain chromosomal disorders, although it is also a normal finding in some families). Test to see whether the toenails fill immediately after blanching from pressure. Normally, newborn legs are bowed as well as short. The sole of the foot appears flat because of an extra pad of fat in the longitudinal arch. The foot of a term newborn has many crisscrossed lines on the sole, covering approximately twothirds of the foot. If these creases cover less than two-thirds of the foot or are absent, suspect immaturity. With a newborn in a supine position, both hips can be flexed and abducted to such an extent (180 degrees) that the knees touch or nearly touch the surface of the bed. If the hip joint seems to lock short of this distance (160 to 170 degrees), hip subluxation (a shallow and poorly formed acetabulum) is suggested (McCarthy & MacEwen, 2007). A further test for subluxation can be elicited by holding the infant’s leg with the fingers on the greater and lesser trochanter and then abducting the hip; if subluxation is present, a “clunk” of the femur head striking the shallow acetabulum can be heard (Ortolani’s sign). If the hip can be felt to actually slip in the socket, this is Barlow’s sign. Subluxated hip may be bilateral but is usually unilateral. It is important that hip subluxation be discovered as early as possible, because correction is most successful if it is initiated early. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 13