| Category | First 4 Hours | 4-8 Hours Past Birth | 8-24 Hours Past Birth |
|---|---|---|---|
| Referral |
Review labor/birth record Review transitional nursing record Check ID bands PRN consults: orthopedics, genetics, infectious disease |
Check ID bands Transfer to mother/baby care at 4-6 hours of age if As parents desire, obtain circumcision permit after their discussion with physician Lactation consult PRN |
Check ID bands every shift |
| Assessments |
Continue assessments begun first hour after birth. Vital signs: TPR, BP PRN, qlh X 4 (skin temp 97.898.6°F, resp may be irregular but within 30-60 per |
Assess newborn’s progress through periods of
reactivity Vital signs: TPR q8h and PRN, BP PRN |
VS q8h. Normal ranges: T, 97.5-99°F; P, 120-160; R, 30-60; BP, 60-80/40-45 mm Hg |
Newborn Assessments:
|
Newborn Assessments:
|
Continue Newborn Assessments:
Expected Outcomes: Vital signs medically acceptable, color pink, assessments WNL, circ site without s/s infection, cord site without s/s infection and clamp removed; newborn behavior WNL |
|
| Teaching/ psychosocial |
Admission activities performed at mother’s bedside if possible, orient to nursery
pm, hand washing, assess teaching needs Teach parents use of bulb syringe, signs of choking, positioning, and when to call for assistance Teach reasons for use of radiant warmer, infant hat, and warmed blankets when out of warmer Discuss/teach infant security, identification |
Reinforce teaching about choking, bulb syringe use, positioning, temperature
maintenance with clothing and blankets Teach infant positioning to facilitate breathing and diges- Teach new parents holding and feeding skills Teach parents soothing and calming techniques |
Final discharge teaching: diapering, normal void and stool patterns, bathing,
nail and cord care, circumcision/uncircumcised penis/genital care and normal characteristics,
rashes, jaundice, sleep/wake cycles, soothing activities, taking temperatures, thermometer
reading Explain s/s of illness and when to call health care provider Infant safety: car seats, immunizations, metabolic screening; on back for sleep Expected Outcomes: Mother/family verbalize comprehension of teaching; demonstrates care capabilities |
| Nursing care management and reports |
Place under radiant warmer Place hat on newborn (decreases convection heat
loss) Suction nares/mouth with bulb syringe pm Keep bulb syringe with infant Attach security sensor Obtain lab tests: blood glucose; as needed obtain blood type, Rh, Coombs on cord blood, HSV culture if parental hx Notify physician’s office for exchange of infant's birth and status Maintain standard precautions |
Wean from radiant warmer (T 98°F axillary) Chemstrips pm; BP pm Oxygen saturation prn Bathe infant if temp >97.8°F 5 Position on side Suction nares prn (esp during second period of reactivity) Obtain peripheral Het per protocol Cord care per protocol (alcohol or triple dye prn) Fold diaper below cord (for plastic diapers, turn plastic layer away from skin) |
Check for hearing test results Weigh before discharge Cord care every shift DC cord clamp before discharge Perform newborn metabolic screening blood tests before discharge Circumcision if indicated. Circumcision care: change diaper prn noting ability to void, follow policy for Gomco or Plastibell care Expected Outcomes: Newborn maintains temp, lab test WNL, cord dry without s/s infection and clamp removed, screening tests accomplished, circ site without s/s infection or bleeding |
| Activity and comfort |
Place under radiant warmer or wrap in prewarmed
blankets until stable Soothe baby as needed with voice, touch, cuddling, nesting in warmer |
Leave in warmer until stable, then swaddle Position on side after each Bleeding |
Place in open crib Swaddle to allow movement of extremities in blanket, including hands to free Expected Outcomes: Infant maintains temp WNL in open crib; infant attempts self-calming |
| Nutrition |
Assist newborn to breastfeed as soon as mother/baby
condition allows Supplement breast only when medically indicated or per agency policy Initiate bottle-feeding within first hour Gavage feed if necessary to prevent hypoglycemia |
Breastfeed on demand, at least q3-4h Teach positions, observe/assist with feeding, breast/nipple care, establishing milk supply, breaking suction, feeding cues, latching on techniques, nutritive suck, burping Bottlefeed on demand, at least q3-6h Determine readiness to feed and feeding tolerance |
Continue breast/bottlefeeding pattern Assess feeding tolerance q4h Discuss normal feeding requirements, signs of hunger and satiation, handling feeding problems, and when to seek help Expected Outcomes: Mother verbalizes knowledge of feeding information; breastfeeds on demand without supplement; bottle—tolerates formula feeding, nipples without problems |
| Elimination | Note first void and stool if not noted at birth | Note all voids, amount and color of stools q4h |
Evaluate all voids and stools color q8h Expected Outcomes: Voids qs; stools qs without difficulty; stool character WNL; diaper area without s/s skin breakdown or rashes |
| Medication |
Prophylactic ophthalmic ointment OU after baby makes eye contact with parents
within 1 hr after birth Administer Aquamephyton IM, dosage according to infant weight per MD/NP |
Hepatitis B injection as ordered by physician after consent signed by parents |
Hepatitis B vaccine before
discharge Expected Outcomes: Baby has received ophthalmic ointment and vitamin K injection; baby has received first hepatitis B vaccine if ordered and parental permission received |
| Discharge planning/ home care | Hepatitis B consent signed Hearing screen consent |
Review/reinforce teaching with mother and significant other Review home preparedness |
Initial newborn screening tests (hearing, blood tests, PKU) before
discharge Bath and feeding classes, videos, or written information given |