Movement and Activities
Maturity
Generally, each facility will have a gestational age maturity guide in the form of a table. The birth attendant observes the infant’s posture, tests flexibility and reflexes, and identifies specific physical characteristics to determine the newborn’s physical maturity. The form will allocate scores and identify criteria related to maturity. If the scores are too low, the newborn is treated as premature.
Behavior
Typical newborns sleep approximately 17 hours a day. They awaken easily and cry when hungry or uncomfortable. Their arms and legs move freely and symmetrically. They often flex their extremities. They are unable to support the weight of the head.
Reflexes
Certain reflexes are present at birth, although the newborn’s nervous system is immature. These reflexes indicate adequate neurologic functioning; their absence indicates abnormalities.
• Rooting reflex: When stroked on the lip or cheek, the newborn reacts by turning the head toward the direction of the stimulus (Fig. 67-4A).
• Palmar grasp reflex: The newborn tightly grasps a finger or other object placed into his or her hand. This reflex disappears as the newborn grows older (Fig. 67-4B).
• Moro’s or startle reflex: Sudden noises or jarring movements cause the newborn to throw out the arms and to draw up the legs (Fig. 67-4C).
• Tonic neck reflex: When the newborn is lying on the back and turns the head to one side, the leg and arm of that side extend, and those of the opposite side flex (Fig. 67-4D).
• Babinski’s reflex: Hold the newborn’s foot and stroke up the lateral edge and across the ball of the foot. The big toe fans out and hyperextends in a positive response (Fig. 67-4E).
• Stepping reflex: The newborn steps with one foot, and then the other, when held upright with the feet touching a surface (Fig. 67-4F).
• Sucking reflex: As the newborn grasps the nipple with the lips, sucking should be automatic.
Other reflexes include gagging, crawling, blinking, sneezing, and coughing.
Senses
Newborns can see shades of light and darkness following birth. They blink in response to bright lights; however, they are unable to focus their eyes for more than a few seconds at a time. They respond to faces by staring.
Babies can hear at the time of birth. Caregivers should talk to them in soothing tones. It is typical for adults to speak in high-pitched voices to a baby; this is a sign of attachment.
Touch is well developed in newborns. They respond to discomfort, such as pain and wetness. Less is known about the senses of smell and taste. Newborns are known to increase sucking when offered glucose water. Research has shown that newborns at 1 week of age are able to distinguish their mother’s milk by smelling their mother’s breast pads.
CARE OF THE NEWBORN AFTER DELIVERY
In a labor-delivery-recovery room (LDR) or a labor-delivery-recovery-postpartum (LDRP) setting where the birth has just taken place or if the baby is transferred from the delivery room to a separate newborn nursery, healthcare personnel who take responsibility for the care of the infant must receive certain information:
• Length of first and second stages of labor
• Length of time the membranes were ruptured
• Type of delivery and any difficulties; use of forceps or vacuum extraction
• Analgesics and anesthetics that were used in delivery
• Newborn’s condition at delivery
• Newborn’s Apgar scores
• Whether resuscitation was needed
• Newborn’s vital signs
• Whether vitamin K was given
• Whether eye prophylaxis was performed
• Whether or not the baby voided or passed the meconium plug or stool
Nursing Alert Report any abnormal signs or symptoms at once. A newborn’s condition can change quickly
Data Gathering
Initial Observations
The first hours after birth are a time of continuing transition for the infant as he or she adapts to life outside the mother’s uterus. If you work in the newborn nursery, you will observe the newborn on admission. Note physical characteristics, including the newborn’s appearance, behavior, and reflexes.
Umbilical Cord. Observe the cord and make certain that the clamp is securely attached. Count the number of vessels in the umbilical cord. Normally, you will find three vessels: two arteries and one vein. If you observe only two vessels, you must report this because it indicates a strong possibility of congenital defects in the newborn.
Nursing Alert Notify the baby’s healthcare provider if there are only two umbilical vessels.
FIGURE 67-4 · (A) Rooting reflex. (B) Palmar grasp reflex. (C) Moro’s reflex (startle reflex). (D) Tonic neck reflex. (E) Babinskis reflex. (F) Stepping reflex.
Measurements. Weigh the newborn immediately after his or her arrival in the newborn nursery. Record the weight on the health record in grams, and convert it to pounds for the mother’s benefit. Measure the length of the baby along with the head and chest circumference. These measurements are often recorded in centimeters (see In Practice: Nursing Procedures 67-3 and 67-4).
Vital Signs. Take respiration, pulse, and temperature, and record them every hour or two immediately after birth and then every 4 hours for the first 24 hours. In the past, the initial temperature was taken rectally to establish the patency of the rectum. Currently, the passage of the meconium (stool) is accepted as validation that the anus is patent. Tympanic and axillary temperatures are considered safe and accurate. Tympanic temperature may be converted to a rectal equivalent.
Ongoing Observations
Respiratory Status. For several hours after birth, continue to observe the newborn’s respiratory status. Respiratory status is normal if the movements of the newborn’s diaphragm and abdominal muscles are synchronized. The newborn’s chest should expand as a whole, and the muscles of the chest wall should not show great effort with breathing. The nares should not flare out with the breath, and the baby should not make grunting noises when breathing.
Observe the baby’s general condition and evaluate respiratory status by skin color, rate of respiration, and general activity (Fig. 67-5). Newborns are obligatory nose breathers, with a respiratory rate of 30 to 60 breaths per minute. The reflex response of opening the mouth to breathe when the nasal passage is blocked is absent in most newborns until they are 3 weeks old. Box 67-2 explains the signs of newborn respiratory distress.
Nursing Alert Immediately report any signs of respiratory distress; an infant in distress can worsen very quickly
Crying. The newborn cries and tightens the muscles in response to sudden loud sounds, changes in position, the feel of something cold touching the skin, or any interference with movements. Crying is the only way a baby can ask for help. He or she cries when hungry, wet, disturbed, uncomfortable, or sick. The cry of the healthy newborn is lusty. The baby who gets more care usually cries less. Hunger cries are healthy, demanding cries, and the newborn may put fingers in the mouth as an additional sign of hunger. After being fed, the baby is quiet unless he or she has swallowed air from the bottle and needs to bubble. The baby relaxes when held, rocked, and patted lightly.
Elimination. The infant should pass its first urine within 24 hours of birth. The nurse must record the number of times the infant urinates daily. Urination is an indication that the kidneys are functioning, and that the baby is getting enough fluid.
The first stool passed by the infant will have a greenish-black, tarry appearance. This stool, called meconium, was formed during fetal life, and is composed of shed skin cells and lanugo hair that the fetus has swallowed. The greenish-black color is due to bile pigments. The first stool is usually passed within 12 hours after birth, and should be recorded in the infant’s hospital record. If no stool has passed by 24 hours of life, the nurse should report this; it could be due to an anatomic defect of the baby.
Examination by the Healthcare Provider
In addition to the Apgar scoring, the baby’s healthcare provider or the birth attendant examines the newborn to determine obvious physical defects. This thorough examination should occur within 24 hours of birth. He or she reviews the chart, including the prenatal as well as the labor and delivery records. The physical examination will include the newborn’s circulatory, respiratory, digestive, and neurologic systems. Patency of the nose and esophagus can be determined by passing a French suction catheter (number 5 to 8) through the newborn’s nares (nose) and into the esophagus. The healthcare provider also carefully observes the reproductive, urinary, musculoskeletal, and endocrine systems. The nurse’s observations and charting during the first few hours are important to this detailed examination.
Maintaining the Infant’s Body Temperature
Because of heat loss and the immaturity of the newborn’s temperature control center, he or she is susceptible to cold-stress. When cold-stress occurs, the newborn is at greater risk of respiratory distress syndrome, acidosis, apnea, or increased respiratory rate. Thus, maintaining a neutral thermal environment for the newborn is important (see Box 67-1).
If the newborn’s temperature is not yet stabilized, an isolette or radiant heat panel should be used. To prevent overheating, the newborn should not wear a diaper or shirt while under the radiant heat panel. The panel responds to the newborn’s skin temperature. An automatic sensor is taped to the abdomen, and the other end attaches to the heat panel. The heat panel then provides more or less warmth based on changes in skin temperature. A thermostatic control allows achievement of the exact skin temperature desired.
Cleansing
Procedures for the initial cleansing of the newborn differ. Sometimes, the father is allowed to cleanse the newborn in the delivery room, or a staff member may merely wipe off blood and some vernix. In some facilities, newborns receive a complete body bath and shampoo after they are stable and their body temperature is within normal limits. The nurse should take care to prevent the newborn from being chilled during any bathing procedure (see In Practice: Nursing Procedure 67-5).
Nursing Alert Be sure to assemble all needed supplies and equipment before starting to bathe the baby Never leave the baby unattended.
FIGURE 67-5 · Grading of neonatal respiratory distress based on the Silverman-Andersen index.
BOX 67-2.
Signs of Newborn Respiratory Distress
|
Chest Movements |
Synchronized movements are normal. A lag on inspiration, or a seesaw movement, is a sign of distress. |
Nares Dilating (Flaring) |
With normal breathing, the nares do not flare out. With distress, flaring may range from minimal to marked. |
|
Intercostal |
The intercostal spaces (spaces |
Expiratory Grunt |
You should not hear a grunting sound with expiration. Grunting, whether heard with a stethoscope or your unaided ear; is abnormal. |
|
Retractions |
between ribs) should not indent. Any indentation is abnormal. |
||
|
Xiphoid Retraction |
The xiphoid process (lower tip of the sternum) should not indent. Any degree of indentation is a sign of distress. |
Learn additional information about a newborn’s respiratory status by observing the color of skin, nailbeds, and oral mucosa; pulse rate; activity level; and character of cry Gasping and tachypnea (rapid breathing) are also abnormal.
Laboratory Screening
When the newborn is a few hours old, hemoglobin and hematocrit tests are often ordered. Because a newborn has increased blood volume for size, the hemoglobin is normally 15 to 18 g/100 mL blood. The normal hematocrit for the newborn is 45% to 60%. Hemoglobin and hematocrit results lower than these normal ranges may indicate anemia.
The physician may also order a test to monitor the newborn’s blood glucose level. A small sample of blood is obtained with a heel stick and tested with a blood glucose monitor. If a Dextrostix heel stick reading is less than 40 to 45 mg/100 mL of blood, it suggests hypoglycemia (see In Practice: Nursing Procedure 67-6).
Most states in the United States require testing for specific diseases. Tests are done to rule out phenylketonuria (PKU), an inherited disorder caused by the body’s inability to digest protein normally. Tests are also made for galactosemia, a hereditary disease in which the newborn cannot digest galactose, a certain type of sugar. Tests of thyroid function can rule out hypothyroidism. Individuals with many of these disorders have a much better prognosis if they are treated before the age of 3 months. Blood tests can also determine the sickle-cell trait and maple syrup urine disease. A test for glucose-6-phosphodehydrogenase (G6PD) deficiency may be done, especially in babies of African, Asian, or Mediterranean origin.
The newborn’s urine may be tested for drugs, such as cocaine or heroin. The presence of these substances indicates maternal substance abuse.
Key Concept The heel stick is the preferred method for obtaining routine blood samples from a newborn. The sample may be used for glucose, PKU, or other necessary blood tests.
