Jorel Franco Antone N.

Tangpuz

BSN II

9/21/16

IMMEDIATE CARE OF THE

NEWBORN
Goals:

To establish, maintain and support respirations.

To provide warmth and prevent hypothermia.

To ensure safety, prevent injury and infection.

To identify actual or potential problems that may require immediate attention.

Establish respiration and maintain clear airway

The very most important need for the new born baby immediately right after birth is a clear
airway to allow the new born to breathe properly since the placenta has stopped functioning
an organ for gas exchange. It is in the maintenance of adequate oxygen supply through
effective respiration that the survival of the baby will greatly depend on.
Those newly born are obligatory nose breathers. Only until 3 weeks after birth will the baby
start opening the mouth to maintain an airway. This is a reflex response to nasal obstruction.
To establish and maintain respirations:
1. Wipe mouth and nose of secretions after the delivery of the head.
2. Suction secretions from mouth and nose.
a. compress bulb syringe before inserting
b. suction mouth first then the nose
c. insert bulb syringe in one side of the mouth
3. Crying infant shows that the infant is breathing. Stimulate the baby to cry if the baby
does not cry spontaneously, or even if the cry is just weak.
a. Do not slap the buttocks; rather, rub the soles of the feet.
b. Stimulate to cry after the secretions have been removed.

c. The normal infant cry is loud and husky. Observe for the following abnormal cry:
i.

High pitched cry this indicates hypoglycaemia and increased intracranial

pressure

ii.

Weak cry prematurity

iii.

Hoarse cry laryngeal stridor

4. Oral mucous may cause the new born to choke, cough, or gag during the first 12 to
18 hours of life. Place the infant in a position that would promote the drainage of
secretions.
a. Trendelenburg position head lower than the body
b. Side lying position if the trendelenburg position is contraindicated, place the
infant in side lying position to allow drainage of mucus from the mouth. Place a
small pillow or rolled towel at the back to prevent the newborn from rolling back
to supine position.
5. Keep the nares patent. Remove mucus and other particles that can become the
cause of obstruction.

Care of the Eyes

Part of the routine care of the new born is to give prophylactic eye treatment against
gonorrhoea, conjunctivitis, or opthalmia neonatorum. Neissaria gonorrhoea, the causative
agent, may be passed on to the fetus during delivery from the vaginal canal. Silver nitrate,
erythromycin, and tetracycline ophthalmic ointments are the drugs used for this purpose.
These drugs are used for eye prophylaxis most commonly because they do not cause
irritation and are more effective against Chlamydial conjunctivitis. They are to be applied
over lower lids of both eyes, then, manipulate eyelids to spread the medication over the
eyes.
Vitamin K or Aquamephyton
The new born has a sterile intestine at the time of its birth and so the new born does not
have the intestinal bacteria that produces vitamin K, which is needed for the formation of

clotting factors. This makes the new born prone to bleeding. To prevent this, .5 (preterm)
and 1 mg (full term) vitamin K or aquamephyton is injected intramuscularly in the newborns
vastus lateralis.
Care of the cord
The cord is clamped and cut about within 30 seconds after the birth. In the DR, the cord is
clamped twice about 8 in from the abdomen and cut in between. When the new born is
brought to the nursery, another clamp is applied to 1 in from the abdomen and the cord is
cut as the second time. The cord and the area around it are cleansed with antiseptic
solution. The manner of cord care will depend on the protocol of the hospital. Cord clamp
may be taken out after 48 hours when the cord has dried. The cord stump usually just dries
and falls within 7-10 days, leaving a granulating area that heals on the next 7-10 days.

Instruction to the mother on cord care:

1.

No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that
cord does not get wet by water or urine.

2.

Do not apply anything on the cord such as baby powder or antibiotic, except the
prescribed antiseptic solution which is 70% alcohol.

3.

Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does
not get wet when the diaper soaks with urine.

4.

Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The
cord dries and separates more rapidly if it is exposed to air.

5.

If you notice the cord to be bleeding, apply firm pressure and check cord clamp if
loose and fasten.

6.

Report any unusual signs and symptoms which indicates infection.

Foul odor in the cord

Presence of discharge

Redness around the cord

The cord remains wet and does not fall off within 7 to 10 days

Newborn fever

ASSESS

HEART RATE

Absent

Below 100

Above 100

RESPIRATION

Absent

Slow

Good crying

MUCLE TONE

Flaccid

Some flexion

Active motion

REFLEX IRRITABILITY

No response

Grimace

Vigorous cry

Body pink,
COLOR

Blue all over

Pink all over

Extremities blue

THE APGAR SCORING SYSTEM

The APGAR Scoring system was developed as a method to assess the newborns adjustment
to the life outside the uterus. It is taken at one minute and five minutes after the birth. With
depressed infants, repeat the depressed infants, the scoring should be repeated every five
minutes as needed. The one minute score indicates the necessity for resuscitation. The five
minute score is more reliable in predicting mortality and neurologic problems. The most
important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability, and
color follows in decreasing order. A heart rate below 100 signifies an asphyxiated baby and
heart rate above 160 signifies distress.

Score:

7 10 Good adjustment, vigorous

Moderately depressed infant, needs airway clearance

Severely depressed infant, in need of resuscitation.

ASSESSING THE AVERAGE NEWBORN

NEWBORN REFLEXES

REFLEX

NORMAL RESPONSE

ABNORMAL RESPONS
E

Head Circumference
34 35 cm
Rooting and
Newborns turns head in direction of
Weak or no response
Temperature
97.6 98.6 F axillary
sucking
stimulus, opens mouth, and begins to
occurs with prematurity,

suck when cheek, lip, or corner of mouth

neurologic
deficit or
Chest Circumference
32 33
cm
is touched with finger
Heart Rate

injury, or central
120 140 bpm

or nipple.

nervous system (CNS)

depression secondary to

Respirations

30 60 bpm

maternal drug ingestion

Weight

Extrusion

2.5 to 3.4 (eg.

kg narcotics).

Newborn pushes tongue outward when

Continuous extrusion of

tip of tongue is touched with finger or

tongue or repetitive

nipple.

tongue thrusting occurs

with CND anomalies and
seizures.

Swallowing

Newborn swallows in coordination with

Gagging, coughing, or

sucking when fluid is placed on back of

regurgitation of fluid

tongue.

may occur, possibly

associated with
cyanosis secondary to
prematurity, neurologic

deficit, or injury;
typically seen after
laryngoscopy.
Bilateral symmetrical extension
and abduction of all extremities, with
thumb and forefinger forming
characteristic C are followed by
adduction of extremities and return to
relaxed flexion when newborns position
changes suddenly or when newborn is
Moro

placed on back on flat surface.

Asymmetrical response
is seen with peripheral
nerve injury (brachial
plexus) or fracture of
clavicle or long bone or
arm or leg. No response
occurs in cases of
severe CNS injury.

Newborn will step with one foot and

then the other in walking motion when
one foot is touched to flat surface.

Asymmetrical response
is seen with CNS or

Stepping

peripheral nerve injury

or fracture of long bone
of leg.

Newborn will attempt to crawl forward

with both arms and legs when placed
on abdomen or flat surface.

Asymmetrical response
is seen with CNS or

Prone crawl

peripheral nerve injury

or fracture of long bone
of leg.

Extremities on side to which head is

turned will extend, and opposite

Tonic neck or
fencing

extremities will flex when newborns

Persistent response

head is turned to one side while resting.

after 4th month may

Response may be absent or incomplete

indicate neurologic

immediately after birth.

injury. Persistent
absence seen in CNS
injury and neurologic
disorders.

Startle

Newborn abducts and flexes all

Absence of response

extremities and may begin to cry when

may indicate neurologic

exposed to sudden movement or loud

deficit or injury.

noise.

Complete and
consistent absence of
response to loud noises
may indicate deafness.
Response may be

absent or diminished
during sleep.

Newborns opposite leg will flex and

then extend rapidly as if trying to

Weak or absent

Crossed

deflect stimulus to other foot when

response is seen with

Extension

placed in supine position; newborn will

peripheral nerve injury

extend one leg in response to stimulus

or fracture of long bone.

on bottom of foot.
Persistent blinking and
Glabellar

Newborn will blink with first 4 or 5 taps

failure to habituate

blink

to bridge of nose when eyes are open.

suggest neurologic
deficit.

Newborns finger will curl around object

Response is diminished

and hold on momentarily when finger is

in prematurity.

placed in palm of

Asymmetry occurs with

newborns hand.

peripheral nerve

Palmar grasp

damage (brachial
plexus) or fracture of
humerus. No response
occurs with severe
neurologic deficit.

Plantar Grasp

Newborns toes will curl downward when

Diminished response

a finger is placed against the base of

occurs with prematurity.

the toes.

No response occurs with

severe neurologic
deficit.

Newborns toes will hyperextend and fan

apart from dorsiflexion of big toe when
one side of foot is stroked upward from
Babinski sign

heel and across ball of

foot.

No response occurs with

CNS deficit.