The Newborn Infant

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.