IMMEDIATE CARE OF THE NEWBORN I.

Ineffective airway clearance r/t nasal and oral secretions from delivery Goal: To promote airway clearance and transitioning of the newborn. 1. Wipe mucus from the face, mouth and nose. Aspirate with bulb syringe. a. If meconium is present before the delivery, mechanical suctioning of the nasopharynx with an 8 or 10 French catheter is done b. Suctioning is done when the head is delivered. 2. Clamp the umbilical cord approximately 2.5 cm (1 inch) fro the abdominal wall with a cord clamp. a. Count the number of vessels in the cord- (AVA), fewer than three has been associated with renal and cardiac anomalies. 3. Evaluate the newborns condition by the APGAR scoring system at least 1 and 5 minutes after birth a. First minute APGAR determines adaptation with labor, 5 Minutes APGAR determines adaptation to extrauterine life. b. NB score 7-10 are free from immediate stress; 4-6 are moderately depressed; and 0-3 is severely depressed. c. APGAR score > 7 at 5 minutes are to be repeated every 5 minutes until 20 minutes have passed, the infant is intubated, or two successive scores of >7 occur. II. Ineffective thermoregulation r/t environment and immature ability for adaptation Goal: Promoting thermoregulation 1. Dry the newborn immediately after delivery, remove wet towels, and place infant on warm dry towels, a wet, small newborn losses up to 200 cal/kg/min in the delivery room through evaporation, convection, conduction and radiation. Drying the infants cuts this heat loss in half. 2. Cover the newborns head with a cotton stocking cap to prevent heat loss. 3. Wrap the newborn in a warm blanket. 4. Place the newborn under a radiant heat warmer, or place the newborn on the mothers abdomen with skin to skin contact. 5. Provide a warm, draft free environment for the newborn. 6. Take the newborns axillary temperature 36.4C and 37.2C III. Risk for injury r/t immature defenses of the newborn Goal: Preventing injury and infection 1. Administer prophylactic treatment against ophthalmic neonatorum (gonorrheal or chlamydial) a. Treatment maybe with erythromycin or tetracycline antibiotic ophthalmic ointment or drops. Given within 1 hour after birth. b. If the mother has a positive gonococcal or chlamydial culture, the newborn will require further treatment.

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c. Mandatory nationwide. Administer a prophylactic injection of vitamin K. this is done to prevent a neonatal hemorrhage during the first few days of life before the infant begins to produce its own vitamin K. Place matching identification tag on the mother and newborn. a. Information must include mothers name, hospital number, newborns sex, date and time of birth. b. If footprints are to be done, remove all vernix from the foot before inking to improve the quality of the footprint. c. Complete all the identification procedures before the infant is taken from the delivery room. Weigh and measure the infant a. Get the anthropometric measurement of the newborn which includes the weight 2,700-4000 g (6-9 lbs), head circumference 33-35 cm (13-14 in), chest circumference 30-33 cm (12-13 in) , abdominal circumference and length 46-56 cm (18-22 in). Administer Hepatitis B Vaccine. a. It is given 12 hours after birth fro the prevention of acute and chronic hepatitis B infection. b. If mother is positive infant will also receive (HBIg) additionally, at 1 month and 6 months of age.

NURSING CARE OF THE NEWBORN I. Physiology of the Newborn The first 24 hours of life constitute a highly vulnerable time, during which the infant must make major physiologic adjustments to extrauterine life. Transitional Stages During the period of postnatal transition, six overlapping stages have identified: Stage 1. II. III. Nursing Assessment Nursing management

PROBLEMS OF INFANTS A. Premature infant The premature infant is an infant born the completion of 37 weeks gestation A low birth weight (LBW) infant is one whose birth weight is less than 2,500g (5.8 lbs), regardless of gestational weight. A very low birth weight (VLBW) infant is one whose birth weight is below 1,500 g, regardless of gestational age Pathophsysiology & Etiology

Maternal factor a. poor nutrition b. diabetes c. drug abuse d. chronic diseases e. multigravida mother younger than 18 yrs of age f. Primigravida mother Older than 40yrs of age

Complications of pregnancy a. PIH b. Bleeding c. Placenta previa/ Abruptio placenta d. Incompetent cervix e. PROM f. Polyhydramnios/ Oligohydramnios g. Chorioamnionitis

Fetal Factors a. Chromosomal abnormalities b. Anatomic abnormalities c. Fetoplacental unit dysfunction

PREMATURE LABOR

PREMATURE DELIVERY OF INFANT 1. 2. 3. 4. 5. Respiratory system problem Digestive system problem Thermoregulation problem Immune system problem Neurologic system problem

B. C. D. E. F.

Postmature Infant Infant of Mother who has Diabetes Hyperbilirubinemia Infant of Substance-Abusing Mother Septicemia Neonatorum