1. Nursing management of the newborn immediately after birth
    1. Assessment:
      1. Mucus in nasophyarynx, oropharynx.
      2. Apgar score: note and record-at 1 and 5 minimum of age.
        1. Score of 7-10: good condition.
        2. Score of 4-6: fair condition; assess for CNS depression.
        3. Score of 0-3: poor condition; requires immediate intervention. Asphyxia neonatorum-fails to breathe spontaneously within 30-60 seconds after birth; HR<100.
      3. Number of vessels in umbilical stump.
      4. Passage of meconium stool, urine.
      5. General physical appearance/status.
        1. Signs of respiratory distress (nasal flaring, grunting, sternal retraction, cyanosis, tachypnea).
        2. Skin condition (meconium-stained, cyanosis, jaundice, lesions).
        3. Cry-presence, pitch, quality.
        4. Signs of birth trauma (lacerations, dislocations, fractures).
        5. Symmetry (absent parts, extra digits, gross malformations, ears, palm creases, sacral dimples).
        6. Molding, caput succedaneum, cephalhematoma.
        7. Assess gestational age.
      6. Identify high-risk infant.
    2. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to excessive nasopharyngeal mucus.
      2. Ineffective breathing pattern related to CNS depression secondary to intrauterine hypoxia narcosis, prematurity, and lack of pulmonary surfactant.
      3. Impaired gas exchange related to respiratory distress.
      4. Fluid volume deficit related to birth trauma; hemolytic jaundice.
      5. Impaired skin integrity related to cord stump.
      6. High risk for injury (biochemical, metabolic) related to impaired thermoregulation.
      7. Ineffective thermoregulation related to environmental conditions/prematurity.
    3. Nursing care plan/implementation:
      1. Goal: ensure patent airway.
        1. Suction mouth first, then nose; when stimulated, sensitive receptors around entrance to nares initiate gasp, causing aspiration of mucus present in mouth.
        2. Suction with bulb syringe.
          1. If deeper suctioning necessary, use DeLee mucus trap attached to suction. Oral use of DeLee is contraindicated due to risk of contact with baby’s secretions (new Delee now available that has no such risk).
          2. Avoid prolonged, vigorous suctioning.
            1. Reduces oxygenation.
            2. May traumatize tissue, cause edema, bleeding, laryngospasm, and cardiac arrhythmia.
        3. Assist gravity drainage of fluids. Position: head dependent (Trendelenburg) and side-lying position.
      2. Goal: maintain body temperature-to conserve energy, preserve store of brown fat, decrease oxygen needs; prevent acidosis. Prevent chilling:
        1. Minimize exposure; dry quickly.
        2. Warm; apply hat.
        3. Take temperature hourly until stable.
      3. Goal: identify infant:
        1. Apply Identiband or name beads.
        2. Take infant’s footprints and maternal fingerprints.
      4. Goal: prevent eye infection (gonorrheal and chlamydial ophthalmia neonatorum). Within 1 hr of birth apply antibiotic ointment in each eye.
      5. Goal: facilitate prompt identification/vigilance for potential neonatal complications.
        1. Record significant data from mother’s chart:
          1. History of pregnancy, diabetes, hypertension, current drug abuse, excessive caffeine, medications, alcohol, malnutrition.
          2. Course of labor, evidence of fetal distress, medications received in labor.
          3. Birth history of anesthesia.
          4. Apgar; resuscitative efforts.
      6. Goal: facilitate prompt identification/interventiofi in hemolytic problems of the newborn.
        1. Collect and send cord blood for appropriate tests:
          1. Blood type and Rh factor.
          2. Coombs test.
        2. Givevitamin K to facilitate clotting.
    4. Evaluation/outcome criteria: successful transition to extrauterine life.
      1. Status satisfactory; all assessment findings within normal limits.
      2. Responsive in bonding process with parents.