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 (Table 4-14) and reflexes (Table 4-15).
     7. Estimate of gestational age (Table 4-16).
   • 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 hr after birth.
        • Check blood sugar (Dextrostix or Chemstrip) at 30 min, 1,2, and 4 hr for infants at risk for hypoglycemia (e.g., SGA, LGA, IDM).
        • First feeding at 1-4 hr of age with sterile water if permissible and if not breastfeeding.
        • Note voiding or meconium stool; report failure to void or defecate within 24 hr.
     7. Goal: promote bonding.
        • Encourage parent-infant interaction (holding, touching, eye contact, talking to infant).
        • Encourage breastfeeding within 1 hr 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 hr daily.
          2. Feeding - from every 2-3 hrs 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 - Table 4-17.
          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 hr after birth.
             • Nonpathologic.
             • Need for hydration.
          8. Identify need for newborn screen after ingestion of milk (done routinely at 24 hr of age and later). Includes screen for congenital hypothyroidism and galactosemia. (See Table 11-2, Unit 11, for other newborn screening procedures.)
          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 hr of life; second dose 1 mo; third dose 6 mo. If infant born to infected mother, hepatitis B vaccine and hepatitis B immune globulin should be administered within 12 hr 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