Documentos de Académico
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M. Rogers-Walker, MSN/Ed, RN
Apgar Scoring
Activity (muscle tone)
0 — Limp; no movement; flaccid
1 — Some flexion of arms and legs
2 — Active motion
Appearance (color)
0 — The baby's whole body is completely bluish-gray or pale
1 — Good color (pink) in body with bluish hands or feet
2 — Good color all over (completely pink)
Respiration (breathing)
0 — Not breathing
1 — Weak cry; may sound like whimpering, slow or irregular breathing
2 — Good, strong cry; normal rate and effort of breathing
Pulmonary System Transition
First baby must take that first breathe
Function of respiration switches
Management
Cardiac System Transition
Closure of the foramen ovale- after cord is
clamped
Common variations
Murmurs
Acrocyanosis
Nursing Responsibilities
Dry and Stimulate- to make
baby cry
Suction (if needed)
Assess heart rate
Weight and identify
Newborn Thermoregulation
Heat production
Brown adipose tissue
Heat loss
Convection
Radiation
Conduction
Response to heat
Nursing Interventions to
Prevent Hypothermia
Dry infant, remove wet
blankets
Apply a hat and warm
blankets
Avoid placing infant on
cold surfaces
Avoid placing infants in
drafts
Place under radiant
warmer if temperature
is unstable- naked
Normal Newborn Vital Signs
Temperature:
Axillary: 36.5-37c (97.7-98.6F)
Rectal: 36.6-37.2c (97.8-99F)
Heart rate:
Active (REM)
Alert states:
Drowsy
Wide awake
Active awake
Crying
Nursing Assessment of the newborn
Newborn Appearance
Head circumference
32–37 cm (12.5-14.5)
Molding
Caput succedaneum
Cephalhematoma
Newborn Measurements
Weight
2,500 – 4,000 g
5 lb 8 oz – 8 lb 13 oz
Average: 3405g
7 lb 8 oz
Length
48–52 cm (18-22 in)
Average: 50cm(20in)
Newborn Appearance
Chest circumference
Average: 32cm (12.5 in)
Evident xiphoid
Ears
Without lesions, cysts, nodules
Sinus tract
Nose
Patent nares bilaterally
Teeth
Tongue
Abdominal and Back Assessment
Abdomen
Round, full, symmetrical, normal bowel sounds
Two arteries, one vein in cord
Brachial and femoral pulses- make sure is
present & strong
Hernia- common in African Americans
Back
Spine intact- nice straight curve
Patent anus
No sacral dimples- can be sign of spinal bifida.
Report to doctor.
Lanugo
Genital and Anal Assessment
Normal finding
Patent anus
Male Findings:
Testes palpable in scrotum
Undescended testes
Female Finding:
Labia & clitoris edematous
Hymenal tag
Pseudomenstruation- spot of
bleeding from the maternal hormone
passing through the babies system
causes this or breast to swell
Skin Assessment
Acrocyanosis
Vernix caseosa- whitish coat when
born. Lubricate and protect their
skin in utero.
Milia- white spots on the nose and
face. It will disapear.
Mongolian spot
Erythema toxicum (newborn rash).
Disappear by itself.
Mongolian spots
Birthmarks
Telangiectacic nevi (stork bites)
Nevus flammeus (pork wine stain)
Nevus vasculosus (strawberry mark)
Birthmark
Neurologic System
Normal reflexes
Blink- reaction to light within 2 hours after birth. Open
and close the eyes.
Sucking
Rooting- stroke the side of face. They should turn to
that side. To see if able to find breast.
Grasp (plantar and palmer)- finger in hand. Clamp.
Moro – when you lift them of the crib a little or through
startle. Their hand come to a “C”. Up to 6 months.
Babinski- finger through feet. Flare till 2 yr. opposite
after that.
Stepping- when u stand them up and move legs like if
they are stepping
Tonic neck- head one side and hand goes other way
General Nursing Care
Erythromycin ointment
First bath
Gestational Age Assessment-
not important
Dubowitz Tool
Neuromuscular Physical maturity
maturity Skin
Posture Lanugo
Square window Plantar surface
Arm recoil Breasts
Popliteal angle Eye and ear
Scarf sign Genitalia
Heel-to-ear
Newborn Nutrition
Calorie requirements:
50 to 55kcal/lb/day or 105-108kcal/kg/day
Breast Milk
Colostrum- provides baby with passive immunity
Transitional
Mature milk
Fore milk
Hind milk
Frequency
1 and a half to 3 hours