MATERNAL AND CHILD NURSING Anthropometric measurements
Crede’s Prophylaxis (eye care)
Vitamin K administration
NEWBORN ASSESSMENT
Assessment of the newborn is
essential to ensure a successful Components
transition.
Anthropometric measurements
Immediate care of the newborn Bathing- Oil bath/ warm water
bath
Airway Cord care
Breathing Dressing/wrapping- mummified
Temperature Eye prophylaxis
Foot printing/Identification
Major time frames Get APGAR score- 1 & 5 mins
HR, RR, TEMP, BP
Immediately after birth Injection of vit K.
Within the first 4 hours after birth
Prior to discharge Temperature
General guidelines Dry immediately
Place infant in a warmer or use
Keep warm during examination droplight
From general to specific Wrap warmly
Least disturbing first
Document ALL abnormal findings Dressing/Wrapping
and provide nursing care
Mummy
Airway and Breathing Wrap in a warm blanket
Cover head with stockinette cap
Suction gently and quickly using
bulb syringe or suction catheter Daily Care
(not used anymore)
Starts in the mouth then the nose Nutrition/feeding
to prevent aspiration Elimination
Stimulate crying by rubbing Weight
Position properly- side lying/ Bathing and hygiene/Grooming
modified t-berg Obtain vital signs
Provide oxygen when necessary Rooming-in
Note for any abnormalities
CARE OF THE NEWBORN
Components
Vital signs
Foot Printing (not used anymore) Proper identification- tag/bracelet
Oil bath/ Warm water bath Conduction- The transfer of body
Cord care/dressing heat to a cooler solid object in
Measurements (Weight and contact with the baby.
anthropometric)
Nursing consideratiions
Proper identification
Keep warm, dry and well
After delivery, gender should be wrapped
determined Keep away from cold objects or
Pertinent records should be outside walls
completed incliuding the ID Perform procedures in warm,
bracelet padded surface
Before transferring to nursery, ID Keep room temperature warm
tag should be applied. Take HR for 1 full minute
Listen for murmurs
Bathing Palpate peripheral pulses
Assess for cyanosis
Oil bath or complete warm water Observe for CP distress
bath Special concerns: (+) prominent
From cleanest to dirtiest part radial pulse=CHD
DO NOT remove vernix caseosa (-) Femoral pulse=Coarctation of
vigorously aorta
Daily cord care Blood pressure
Keep cord dry and clean and Not routinely measured UNLESS
clamp secured in distress or CHD is suspected
DO NOT cover with diaper At birth: 80/46 mmHG
Note for any signs of bleeding or After birth: 65/41 mmHG
drainage from the cord and other Using Doppler UTZ
abnormalities
Sponge bath until cord falls off.
Pulse
Vital signs
Awake: 120-160 bpm- 120-140
Radiation- The transfer of heat to bpm
a cooler object not in contact with Asleep: 90-110 bpm
the baby Crying: 180 bpm
Evaporation- Loss of heat Rhythm: irregular, immaturity of
through conversion of a liquid to a cardiac regulatory center in the
vapor medulla
Convection- The flow of heat from Duration: 1 full minute, not crying
the body surface to cooler Site: Apical
surrounding air
Respiration
Characteristics:
Abdominal breathers, gentle,
quiet, rapid but shallow,
mayhave the short period of
apnea (<15 secs) and irregular
without cyanosis –periodic
respirations
Rate: 30-60 cpm
Duration: 1 full minute
Nursing considerations
Position on side
Suction PRN
Observe for respiratory distress
Administer oxygen via hood PRN
and as prescribed
Temperature
Site: axillary not rectal
Duration: 3mins
Normal range: 36.5-37.6 C
Stabilizes within 8-12 hrs
Moinitor q 30 mins until stable for
2 hrs then q 8 hrs
APGAR SCORING SYSTEM
Standardized evaluation of the
newborn
Perform 1 minute and 5 minutes
after birth
Involves (5) indicators:
Activity/Muscle tone
Pulse/Heart rate
Grimace/ reflex irritability/ Silverman-Anderson Index
responsiveness
Appearance/skin color Perform to observe for signs of
Respiration/breathing respiratory distress
Chest lag
Retractions Knees and legs straightened or in
Nasal flaring FROG position
Expiratory grunting
SKIN
Cyanosis/Acrocyanosis
Pallor
Jaundice- Under natural light.
Blanch skin over the chest or tip
of the nose
Meconium staining- Over the
skin, fingernails and umbilical
cord, due to passage of
meconium in utero r/t fetal
hypoxia
Acrocyasnosis- Bluish
discoloration of palms and hands
and soles of feet
Due to immature peripheral
circulation
Exacerbated by cold
temperatures
GENERAL APPEARANCE Normal within 1st 24 hrs
Pallor/cyanosis- May iniodicate
The first 24 hours of life hypothermia, infection, anemia,
The first 24 hrs of life is a very hypoglycemia, cardiac,
significant and a higly vulnerable respiratory or neurological
time due to critical transition from problems
intrauterine to extrauterine life. Lanugo- found after 20 wks of
gestation on the entire body
Posture except the palms, and soles. It is
Full term: a fine, downy hair that cobvers
Symmetric the shoiulders, back and upper
Face turned to side arms
Flexed extremeties
Nursing considerations
Hands tightly fisted with the
thumb covered by the fingers
More mature, less lanugo
Special concerns My disappear within 2wks
Preterm: woolly patches of
Asymmertric lanugo on skin and head
Fractured clavicle or humerus Post term: Parchment-like skin
w/o lanugo
Nerve impulse (Erb- Duchenne’s
Paralysis)
Breech presentation
Physiologic Physiologic: not more than 5
mg/dl per day
FT: after the first 24 hrs (2-7 Pathologic: more than 15-20
days) mg/dl
PT: after the first 48 hrs Maintain hydration
Peaks at 5-7 days and Place in bilirubin lights as needed
disappears by the 2nd week Provide emotional support to
Due to immaturity of the liver parents
Usually found over the face,
upper body and conjunctiva of BIRTHMARKS
eyes
Strawberry marks
Pathologic
Nevus Vasculosis or Capillary
Within 1st24 hrs Hemangioma
May indicate early hemolysis of Dark red, raised lobulated tumor
RBC or underlying disease Head, neck trunk and extremeties
process After 7-9 years of age
Duration: FT: 1 wk, PT: 2 wks
Desquamation
Nursing considerations
Dryness/ peeling of the skin
Under natural loght Usually occurs after 24-36 hrs
Assess for: Marked scaliness and
Color desquamation signs of post
Hair distribution maturity
Turgor/texture
Pigmentation/birthmarks Salmon patches
Other skin marks
Seen commonly in NB
Skin color More on Caucasian
AKA: naevus simplex, “Angel
Velvety smooth and puffy esp at kisses” ( when on the forehead or
the legs, dorsal aspects of hands eyelids,) and stork bites ( over the
and feet and in the scrotum or nape of the neck )
labia Midline malformations consisting
Pinkish red to pinkish brown to of ectatic capillaries in the upper
yellow dermis with normal overlying skin.
Ruddy or reddish due to
increased RBC and decreased Petechiae
subQ tissues
Pinpoint hemorrhages on skin
Management of jaundice Di]ue to increased vascular
pressure infection or
Monitoring srum bilirubin levels thrombocytopenia
Within 48 hrs PWS involving the forehead (V1
area of the trigeminal nerve) eye
Ecchymosis abnormalities (choroidal vascular
abnormalities, glaucoma,) and
Bruises leptomeningeal and brain
As a result of rupture of blood abnormalities. (Vascular
vessels malformations, calcifications, or
May appear over the presenting cerebral atrophy)
part as a result of trauma during
delivery Errythema toxicum
May also indicate infection of
bleeding problems Newborn rash
Small, white, yellow, or pink to
Café au Lait red popular rash
Trunk, face and extremeties
tan or light brown macules or Within 48hrs
patches
No pathologic significance, if <3 Stork bites
cm in length and <6 in number
If >3 or 6 = cutaneous Telangiectatic nevi
neurofibromatosis Flat, red orn purple lesions
Back of neck, lower occiput,
Vernix Caseosa upper eyelid and the bridge of the
nose
Protective cheesy-like, gray-white After 2 yrs of age
fatty substance
FT: skin folds under the arms and Port-wine stains
in the groin under the scrotum or
in the labia Nevus Flammeus or Capillary
Nursing consideration: Use baby Angioma
oil, Do not attempt to remove Capillary malformation
viogorously Flat red to purple shaprly
demarcated dense areas beneath
the capillaries
Harlequin Face
Does not fade with time
When on the side, dependent ‘Associated with Sturge-Weber
side turns red and upper side/half syndrome
turns pale
Due to gravity and vasomotor Mottling
instability or immature circulation
Skin resembles a clown’s suit Cutis marmorata
Reticulated pattern of constricted
Sturge-weber syndrome capillaries and venues due to
vasomotor instability in immature Due to rupture of capillaries as a
infants resultbof trauma
Bluish mottlingbor marbling of Does nkt crossed suture lines’
skin in reponse to chilling, stress Several weeks
or overstimulation.
Caput Succeedaneum
Mongolian spots Swelling of the soft toissues of
the scalp
Blue-green or gray pigmnentation Due to pressure
Lower back, sacrum and buttocks Crosses the suture lines
Disappears by 4 years of age Presenting part
3 days after birth
Milia
Forcep marks
Multiple yellow or pearly white
papules approx.. 1 mm wide U-shaped bruising usually on the
Due to enlarged or clogged cheeks after forcep delivery
sebaceous gland
Usually found on the nose, chin,
cheeks, eyebrows, and forehead
ANTHROPOMETRIC
Craniotabes MEASUREMENTS
Localized softenimhg of the Head circumference (HC)
cranial bones
Can be indented by pressure of 33-35.5 cm (13-14 inches)
fingers technique, using tape measure
Most common among 1st born from the most prominent part of
babies, pathological in older the occiput to just above the
child-metaboloc disorder eyebrows
Caused by the pressure of the !/3 the size of an adult’s head
fetal skull against the mother’s Disproportionately Large for its
pelvic bone in utero body
HC should be = or 2cm >CC
Craniosynostosis
Chest circumference (CC)
Premature closure of the
fontanelles 30-33 cm (12-13 inches)
technique, using tape measure
Cephalhematoma from the lower edge of the
scapulas to directly over the
Subperiostial hemorrhage with nipple line anteriorly
collection blood
CC should be = or < 2cm than
HC Mouth
Weight pink, moist gums
5.5 to 9.5 lbs ( 2,500-4,300 gms) intact soft and hard palates
filipinos: 6.5 lbs (+) epstein’s pearls
70-75 % tbw is water uvula midline
LBW= below 2,500 gms, tongue moves freely, symmetrical
regardless of AOG with short frenulum
(+) extrusion and gag reflexes
Length small mouth or large tounge=
chromosomal problems
45-55 cm (18-22 inches) (+) white patches on tongue or
Average: 50 cm side of the cheek = oral thrush
Techniques: using tape measure
Supine with legs extended Crown
to rump and headb to heel
Neck
Ears
Short, thick, in midline
Accessory tragus: remnant of the Able to flex and extend but
1st branchial arch cannot support the full weight of
Congenital preauricular sinus: head
ends blindly risk for infection Creased with skin folds
Soft and pliable: with firm Trachea midline
cartilage Thyroid gland not palpable
Pinna should be at the level of Intact clavicle
outer canthus of the eye
(+) low set ears= renal or
chromosomal abnormalities
may be congested and hear well Chest
after few days
CC= or <2cm than HC
Cylindrical equal AP:T diameters
Symmetrical
Nose Abdominal breathers
Small and narrow Eyes
Flattened, midline
Nasal breathers (+) transient strabismus due to
(+) periodic sneezing weak EOM
reactive to strong odors Ablke to move and fixate
(+) Flaring= respiratory distress momentarily
(+) low nasal bridge= down’s (+) Red reflex if (-) cataract
syndrome
(+) edema on eyelids r/t pressure
during delivery or effects of
medication GIT
(-) tear formatiomn begins at 2-3
mos Capacity: 90 ml with rapid
intestinal peristalsis (2 ½ to 3hrs)
Nursing considerations Bowel syndrome: (+) within 1-2
hrs after birth
administer eye medications within Presence of mass, distention,
1 hr after birth to orevent depression or protrusion
Ophthalmia neonatorum (+) scaphoid= diaphragmatic
doc: erythromycin 0.5% hernia
tetracycline 1% (+) distended= LGIT
Silver nitrate 1% obstruction/mass
From inner to outer canthus of
the eye conjunctival sac Breast
Face (+) bronchial sounds
(+) breast engorgement subsides
Facial movement and symmetry after 2 wks
Symmetry, size, shape, and (+) prominent/edematous nipple
spacing of eyes, nose and ears (+) Accessory nipples
(+) Witch milk
Head
Abdomen
Fontanelles soft spot
AF (12-18 mos) Umbilical cord
PF ( 2-3 mos or 8-12 wks) 2 arteries, 1 vein
Bulging or sunken white and gelatinous immediately
Sutures- overriding or separated after birth
Head lag- common when pulling begins in dry between 1-2 hrs
newborn to a sitting position following birth
When prone, NB should be able blackened or shriveled between
to lift the head slightly and turn 2-3 days
head from side to side dried and gradually falls of after 7
days
What to assess
Back
For symmetry, shape, swelling,
movement Spine
Soft, pliable, moves easily Straight, posture flexed
With some molding if round and Supports head momentarily
well-shaped Arms and legs flexed
Measure HC: HC= or > CC Chin flexed on upper chest
Check for protrusion, excessive
or poor muscle contractions = Breastfeeding can usually begin
CNS damage immediately after birth
Bottlefeeding may be started with
sterile water to 4hrs after birth
prior to formula feeding
Burp durimng and after feeding
Genitals Position properly during and after
feeding
Female
Labia edematous Extremeties
Clitoris: enlarged
(+) Smegma Flexed, full ROM, symmetrical
pseudomenstruation possible Clenched fists, flatsoles
visible hymen tag With 10 fingers and toes in each
first voiding within 24 hrs hand
Legs bowed
Male Even gluteal folds
prepuce covers glans penis REFLEXES
(+) adherent foreskin = phismosis
scrotum: edematous SWALLOWING
(+) ventral/dorsal =
hypo/epispadias Occurs spontaneously after
meatus: central sucking and obtaining fluids
testes: distendend NEVER disappear
undescended=Cryptorchidism Newborn swallows in
coordination with sucking without
Anus gagging, coughing or vomiting
Check patency
First stool (Meconium) within 1srt TONIC NECK/FENCING
24 hrs
Sticky, tarlike, blackish-green, While the baby is falling asleep or
odorless material sleeping, gently and quickly turn
Transitional stool is within 2-10 the head to one side
days after birth As the baby faces the left side,
If breastfed: golden yellow, the left arm and the leg extend
mushy, more frequent 3-4x and outward while the right arm or leg
sweet smelling flexes and vice versa
If bottlefed: pale yellow, firm, less Disappears within 3-4 mos
frequent 2-3x with more
nioticeable odor PALMAR (GRASPING)/ PLANTAR
Nursing comdiderations
Place a finger in the palm of the at the heel of the foot to the ball
baby’s hand then place a finger at of the foot
the base of the base the toes Dorsiflexion of a big toe and
Fingers will curt or grasp the fanning of little toes
examiner’s finger and the toes Disappears starts atv3 mos to 1
will curl downward yr
Palmar fades within 3-4 mos Disappearance indicates maturity
Plantar fades within 8 mos of CNS
SUCKING/ROOTING
MORO
Touch the lip, cheek, or corner of
Hold baby in a semi sitting the mouth
position then allow the head and Turns head toward the nipple,
trunk to fall backward to atleast a opens mouth takes hold of the
30 degree angle nipple and sucks
Symmetrically abducts and Disappears after 3-4 hrs up to 1yr
extends the arms: fans the
fingers out and forms a C with the EXTRUSION
thumb and the forefinger and
adducts the arms to an Anything place on the anterior
embracing position and returns to portion of the tounge will be spit
a relaxed state. outr
To prevent swallowing of inedible
STEPPING/WALKING/DANCING substances
Disappears after 4 mos
Hold baby in anstanding position Disappearance indicates
allowing one foot to touch a readiness for semi-solid to solid
surface allowing one foot to touch foods
a surface
Stimulates walking by
alternatively flexing and
extending feet Infant care skills
Disappears after 3-4 mos
Holding the baby
STARTLE Football hold
Cradle hold
Best elicited if baby is 24 hrs old Shoulder hold
Make a loud noise or claps hands
Baby;’s arms adduct while elbows Football hold
flex with fists clenched
Disappears within 4 mos Purpose: to carry on one hand
free
BABINSKI A holding technique in bathing a
baby use for small babies
Gently stroke upward along the
lateral aspect of the sole starting Procedure:
Performed after 24 hrs of life up
Slide forearm under his/her back to 3 days except for patient in
Support neck and head with your ICU must be tested by 7 days.
hand
Press his arm firmly against your Assessment of the gestational age
side
His head face you Dubowitz maturity scale
Infant’s feet tucked under your Gestational rating scale
elbow NB are observed and tested
according to the criteria
Shoulder hold Help determine whether the NB
needs immediate high-risk
Purpose: use for burping nursery intervention
Procedure:
Draw baby towards your chest
with one forearm
Bracing his back and your hand
cradling his head
Support your baby’s bottom and
thighs with your other arm
Gently press his head against
shoulder
Cradle Hold BALLARD SCORING
Purpose: Use for feeding and Completed in 3-4 min
cuddling a baby 2 portions: physical maturity and
neuromuscular maturity
Procedure
Support head in the crook of your
arm
Encircle the body with your arm
Press baby firmly against your
side
Use other hand to support bottom
and thigh
Newborn screening
The newborn screening reference
center is an office under the
national institutes of health under
RA 9288
USHER’S CRITERIA
