THE NEWBORN INFANT

General overview: Effective nursing care of the newhorn infant is based on: (1) knowledge of the conditions present during fetal life; (2) requirements for independent extrauterine life; and (3) alterations needed for successful transition. The first 24 hours are the most hazardous.

1. Biological foundations of neonatal adaptation - general aspects:
   • Fetal anatomy and physiology
     1. Fetal circulation - four intrauterine structures that differ from extrauterine structures:
        • Umbilical vein - carries oxygen and nutrient-enriched blood from placenta to ductus venosus and liver.
        • Ductus venosus - connects to inferior vena cava; allows most blood to bypass liver.
        • Foramen ovale - allows fetal blood to bypass fetal lungs by shunting it from right atrium into left atrium.
        • Ductus arteriosus - allows fetal blood to bypass fetal lungs by shunting it from pulmonary artery into aorta.
        • Umbilical arteries (two) - allow return of deoxygenated blood to the placenta.
     2. Umbilical cord - extends from fetus to center of placenta: usually 50 cm (18-22 inches) long and 1-2 cm (½-1 inch) in diameter. Contains:
        • Wharton’s jelly - protects umbilical vessels from pressure, cord “kinking,” and interference with fetal-placental circulation.
        • Umbilical vein - carries oxygen and nutrients from placenta to fetus.
        • Two umbilical arteries - carry deoxygenated blood and fetal wastes from fetus to placenta. Note: Absence of one artery indicates need to rule out intraabdominal anomalies.
     3. Characteristics of fetal blood
        • Fetal hemoglobin (Hb_f)
          1. Higher oxygen - carrying capacity than adult hemoglobin.
          2. Releases oxygen easily to fetal tissues.
          3. Ensures high fetal oxygenation.
          4. Normal range at term: 12-22 g/dl; average: 15-20 g/dl.
        • Total blood volume at term: 85 mL/kg body weight; Het: 38-62%, average 53%; RBC 3-7 million, average 4.9 million/U.
   • Extrauterine adaptation: tasks
     1. Establish and maintain ventilation, successful gas transfer - requires patent airway and adequate pulmonary surfactant.
     2. Modify circulatory patterns - requires closure of fetal structures.
     3. Absorb and utilize fluids and nutrients.
     4. Excrete body wastes.
     5. Establish and maintain thermal stability.
   • Nursing care plan/implementation
     1. Facilitate successful transition to independent life.
     2. Protect infant from physiological stress and environmental hazards.
     3. Encourage development of a strong family unit.


2. Admission/assessment: 1 - 4 hours after birth
   • Admission assessment of normal, term neonate
     1. Color and reactivity.
     2. General appearance, symmetry.
     3. Length and weight.
     4. Head and chest circumferences.
     5. Vital signs:
        • Axillary temperature.
        • Respirations (check rate, character, rhythm).
        • Apical pulse.
     6. General physical assessment and reflexes.
     7. Estimate of gestational age.
   • Analysis/nursing diagnosis:
     1. Altered health maintenance related to separation from maternal support system.
     2. Impaired skin integrity related to umbilical stump; incontinence of urine and meconium stool; skin penetration by scalp electrode, injections, heel stick, scalpel during cesarean birth; abrasion from obstetric forceps.
     3. Ineffective airway clearance related to excessive mucus.
     4. Pain related to environmental stimuli.
     5. Ineffective thermoregulation related to immature temperature regulation mechanism.
   • Nursing care plan/implementation:
     1. Goal: promote effective gas transport.
        • Maintain patent airway - to promote effective gas exchange and respiratory function.
        • Position: right side-lying, head dependent (gravity drainage of fluid, mucus).
        • Suction pm with bulb syringe for mucus.
     2. Goal: establish/maintain thermal stability.
        • Avoid chilling - to prevent metabolic acidosis.
        • Dry, wrap, and apply hat.
        • Place in heated crib.
        • Monitor vital signs hourly until stable.
     3. Goal: reduce possibility of blood loss.
        • Check cord clamp for security.
        • Administer vitamin K injection, as ordered, in anterior or lateral thigh muscle - to stimulate blood coagulability.
     4. Goal: prevent infection.
        • Administer antibiotic treatment to eyes (if not performed in birth room) - to prevent ophthalmia neonatorum.
        • Treat cord stump (alcohol, Triple Dye antibiotic ointment), as ordered.
        • Use standard precautions.
     5. Goal: promote comfort and cleanliness. Admission bath when temperature stable.
     6. Goal: promote nutrition, hydration, elimination.
        • Encourage breastfeeding within 1 hour after birth.
        • Check blood sugar (Dextrostix or Chemstrip) at 30 minutes, 1, 2, and 4 hours for infants at risk for hypoglycemia (e.g., SGA, LGA, IDM).
        • First feeding at 1-4 hours of age with sterile water if permissible and if not breastfeeding.
        • Note voiding or meconium stool; report failure to void or defecate within 24 hours.
     7. Goal: promote bonding.
        • Encourage parent-infant interaction (holding, touching, eye contact, talking to infant).
        • Encourage breastfeeding within 1 hour of birth, if applicable.
        • Encourage parent participation in infant care - to develop confidence and competence in caring for newborn.
          1. Assist with initial efforts at feeding.
          2. Discuss and demonstrate positioning and burping techniques.
          3. Demonstrate/assist with basic care procedures, as necessary:
             • Bath.
             • Cord care.
             • Diapering.
             • Aid parents in distinguishing normal vs. abnormal newborn characteristics.
     8. Goal: health teaching - to provide anticipatory guidance for discharge.
        • Facilitate sibling bonding.
        • Describe/discuss normal newborn behavior:
          1. Sleeping - almost continual (wakes only to feed) or 12-16 hours daily.
          2. Feeding - from every 2-3 hours to longer intervals; establish own pattern; breastfed babies feed more often.
          3. Weight loss - 5-10% in first few days; regained in 7-14 days.
          4. Stools.
          5. Cord care - drops off in 7-10 days
             • Keep clean and dry.
             • Alcohol to stump.
             • HIV precautions.
          6. Circumcision care
             • Keep clean and dry; heals rapidly.
             • Watch for bleeding.
             • Petroleum jelly, gauze prn, if ordered.
             • Do not remove yellowish exudate.
          7. Physiologic jaundice - occurs 24-72 hours after birth.
             • Nonpathologic.
             • Need for hydration.
          8. Identify need for newborn screen after ingestion of milk (done routinely at 24 hours of age and later). Includes screen for congenital hypothyroidism and galactosemia.
          9. Describe suggested sensory stimulation modalities (mobiles, color, music).
          10. Discuss safety precautions:
              • Position on back for sleep.
              • Infant seat for travel and home safety.
              • Maintaining contact/control over infant to prevent falls, drowning in bath.
              • Instruct parents in infant cardiopulmonary resuscitation (CPR).
              • Hepatitis B vaccination - first dose can be given 24-48 hours of life; second dose 1 month; third dose 6 months. If infant born to infected mother, hepatitis B vaccine and hepatitis B immune globulin should be administered within 12 hours of birth.
          11. Describe signs of common health problems to be reported promptly:
              • Diarrhea, constipation.
              • Colic, vomiting.
              • Rash, jaundice.
              • Differentiation from normal patterns.
   • Evaluation/outcome criteria:
     1. Infant demonstrates successful transition to independent life:
        • Nurses well.
        • Normal feeding, sleeping, elimination patterns.
        • No evidence of infection or abnormality.
     2. Mother/family evidences bonding.
        • Eye contact.
        • Stroking, cuddling
        • Crooning, calling baby by name, talking to infant
     3. Mother demostrates comfort and skills in basic newborn care
     4. Mother verbalizes understanding of subjects discussed:
        • Safety precautions
        • Health maintenance actions
        • Signs of normal infant behavior and health