Neonate

Learning Guide - 2

Text Book
Kozier & Erbs Fundamentals of Nursing
concepts, process and practice. 8th edition.
Chapter 21
Pages: 369 373.

Neonate
Age: From birth to 28 days.
Basic task: to survive
The neonate has to develop breathing, sucking, feeding,
swallowing, digesting, eliminating and sleeping patterns.
The neonates ability to survive is assessed using the
APGAR score.
The assessment is done at 1 and 5 minutes after birth. .
The item scored are heart rate, respiratory effort, muscle
tone, reflex irritability and colour.
Each item is given a score of 0, 1& 2.

APGAR SCORE
A

Signs

Heart rate

0
Absent

Slow (less than

100/mt.)

More than
100/mt.

Resp. effort Absent

Slow, irregular

Good, Crying

Muscle
tone

Limp

Some flexion in
extremities

Active
motion

Reflex
irritability

No
response

Grimace

Coughs &
Sneezes

Colour

Blue / pale

Body pink,
Completely
extremities blue pink.

Score

Vital signs
Temperature 36.5-37.5oC.
Pulse

Respiration

BP

120-150 beats/mt. Irregular. Count the

apical pulse for 1 full minute.
35-50 breaths/mt. Quiet, rapid and
shallow breathing. Count for 1 full
minute. Respiratory movements are
abdominal.
65/30 to 90/60 mm of Hg. Doppler or
flush method is used to measure BP.

Measurements
Weight: 2.5-4.0 Kg.
After birth the newborn loses 5-10% of body
weight due to fluid loss.
The weight gain is 5-7 oz (150-210 gm) per
week for the first 6 months.

Measurements
Length: 50 cm. Female babies are smaller.
Crown-to-rump length(CRL), sitting height:
Same as head circumference.
Head circumference: 35 cm (normocephaly)
Chest circumference: 30.5-33cm.

Head
The head of most newborn babies are misshapen because of
the molding of the head that occurs during vaginal deliveries.
Molding is possible because the skull bones are not ossified
at the time of birth.
Fontanel: The space or gap present in the skull of a newborn
where more than two bones joint. The most important
fontanels are
Anterior fontanel: At the junction of the two parietal and the two
frontal bones. It is diamond shaped and 6cm in length and
4cm in width.
Posterior fontanel: Located between the parietal and occipital
bones. Small and triangular in shape. Closes by 4-8 weeks
after birth.
Caput succedaneum: A soft swelling / edema of the head due
to the pressure of vaginal delivery. Disappears on the 3rd day.
Cephal hematoma: Accumulation of blood between the
periosteum and the flat skull bone due to the pressure of
vaginal birth. Disappears after some weeks.

Skin
Skin is red or dark pink or reddish black in color, with
good elasticity or turgor.
Skin is soft and covered with lanugo (fine hair).
The secretions from sebaceous glands and
epithelial cells form a cheese like, greasy, yellowish
white substance sticking to the skin. It is called
vernix caseosa. Vernix is more abundant in the
folds of the skin and between the labia.
Touch is the most highly developed sense for
the newborn.

Skin - findings
Desquamation:Peeling of skin occured in the first 2-4 weeks of life.
Milia: Tiny white papillae seen on the nose and chin.
Physiologic jaundice (Icterus neonatorum): Jaundice appearing
between 3-7 days of birth due to the immaturity of the liver.
Disappears spontaneously. Exposing the newborn to Sunlight will be
beneficial.
Telangiectic nevi (stork bites): Flat red marks on the skin.
Mongolian spots: Slate colored spots on the buttocks or lower back.
Acrocyanosis: Symmetric cyanosis of the extremities.
Harlequin color change: The neonate after being placed on a side for
several minutes, shows color difference between the two longitudinal
halves of the body. The lower half appears pink and upper half
appears pale.
Erythema toxicum: A pink papular rash on which vesicles may be
present.
The sweat glands become active by the end of the second week.

Eyes
The eye movements are not coordinated. Eye lids may
be edematous for 2 days. The newborn can see large
objects at a distance of 20-25cm away and responds to
changes in the intensity of light by blinking the eyes.
Lacrimal fluid is present in the eyes which prevents
drying of the conjunctiva and cleanse the eyes.
Subconjunctival hemorrhage: Hemorrhage into the
conjunctiva due to the pressure on the head during
vaginal delivery. Disappears in 2-3 weeks.
Ophthalmia neonatorum: Eye infection due to gonococci.

Ears
The top of pinna should be in a line with the
inner and outer canthi of the eyes.
The pinna is very soft. The nurse must make
sure that the ear is flat against the head while
turning the neonate to sides.
The hearing is not clear for the first few days
because of the presence of fluid in the middle
ear.
The neonate can hear sounds and responds to
loud sounds with startle reflex.

Nose
Nostrils are narrow and easily obstructed with
mucus. Extra mucus should be removed by
suction.
Neonate can breath only through the nose.
The neonate can smell breast milk and search
for the nipple.

Mouth
The mouth is pink in color. The tongue is large and
sucking pads are present in the cheeks. No salivation is
seen in the mouth.
The newborn can sense tastes and prefers sweet taste.
Precocious (supernumerary) teeth: Presence of one or
two teeth in the newborn. Should be removed if they are
loose or interfere with breast feeding. Spontaneously
comes out before the eruption of teeth.
Epstein pearls: Cysts formed by epithelial cells.
Disappear after a week.
Oral thrush (moniliasis): Fungal infection in the mouth.
Should be treated with antifungal agents like nystatin.
Other abnormalities are cleft lip and palate.

Chest
Cylindrical in shape.
Uses diaphragm and abdominal muscles for
breathing.
The breasts may be swollen due to the presence
of maternal hormones (breast engorgement). A
pale milky fluid may be expressed (witchs milk).
It disappears in 2-4 weeks.

Abdomen
Rounded and protuberant. Bowel sounds are
heard soon after birth.
Umbilical cord: The umbilical cord is bluish white
at the time of birth. Contains two umbilical
arteries and one vein. The umbilical cord
sloughs off by 6-10 days. The umbilical cord
must be examined for any abnormalities and
signs of infection moisture, redness, warmth or
foul smelling discharge.

GIT
The cardiac sphincter is not well developed. The
newborn has to be bubbled (burped) after
feeding to expel the swallowed air. If the air is
not expelled the neonate may vomit or the air
pass into the intestines causing colic.
At birth the stomach capacity is 1-2 oz. (30-60
ml).
The gastric emptying time is 2-3 hours.

Elimination
The kidneys are immature and pass large
volumes of dilute urine.
The first stool of the baby is called meconium. It
is greenish black in color and sticky. Neonate
has to pass meconium within 24 hours of birth.
Stools passed in the first week after passing
meconium are called transitional stools.Stools of
the breastfed infants are yellow and pasty.
Formula fed infants pass light yellow and hard
stool with offensive smell.

Genitalia
In male newborns scrotum may be edematous
immediately after birth. The skin of the scrotum
is deeply rugated and darker in color in full term
infants. Testes should be palpated in the
scrotum.
In female neonates labia majora covers labia
minora and clitoris. Blood tinged vaginal
discharge (pseudomenstruation) may be present
due to the presence of maternal hormones.

Extremities
Should be symmetric and in range of motion.
The legs are small, short and bowed outward
with the feet turned inward, similar to fetal
position. The feet are flat.
The arms are short, plump. The fingers short
with nails smooth and soft reaching the finger
tips. The hands are clenched.
The common anomalies of the extremities are
club foot, syndactyly (union of fingers) and
polydactyly (extra fingers).

Blood
Blood volume 80-110 ml/kg body weight. (10-20% of body wt)
RBC count
6 million/mm3 (once the respiration is established
the need for high erythrocyte count decreases and the count
starts coming down).
WBC count
15000-45000/mm3
Hb
Hematocrit

17-18 g/dL

S. bilirubin

1-4 mg%

45-50%

Blood coagulation: Newborn have low blood levels of vitamin K

due to the lack of the normal intestinal flora synthesizing it and
therefore have prolonged prothrombin time and clotting time.
Newborns should be given 1 mg of vit K as IM injection.

Sleep

Approximately 18-22 hours a day and awakening

for 3-4 hours.

Muscular development
The movement of the neonate are random and
uncoordinated.
While holding the neonate the head and back
should be well supported.
Any decrease in muscle tone should be
investigated for cerebral palsy, necrosis or
shock.

Nervous system
Immature. The movements are general and
diffuse.
The response to stimuli are mainly by the
midbrain and reflexes of the spinal cord. As soon
as the myelination of the nerve fibers occur the
movements are better coordinated by the higher
cerebral centers.

The reflexes of the neonate

Neonatal reflexes: Newborns responses to
particular stimuli. Absence of a reflex may
indicate a pathological condition.

Neonatal reflexes
Rooting reflex: The infant turns his head toward
an object that touches his cheek.
Sucking reflex: The infant starts sucking
movements when his lips are stimulated.
Swallowing reflex: Accompanied by sucking
infant swallows food reaching the posterior of
mouth.
Extrusion: Substance placed on the anterior
position of tongue are extruded to prevent
swallowing. Disappears by 4 months.

Neonatal reflexes
Moro (Startle) reflex:
Sudden change in
equilibrium causes
sudden extension and
abduction of
extremities. Baby fans
fingers. This is
followed by flexion
and adduction. The
baby cries.

Neonatal reflexes
Palmar grasp: When a pen or finger is placed in
newborns palm, the baby grasps it by closing fingers.
Plantar grasp: Elicited by touching the sole of the foot at
the base of the toes. The babys toes grasp around very
small objects.
Stepping / placing reflex: Hold the infant upright. Briskly
place his feet against a table. Baby lifts his foot as if
stepping on the table.

Neonatal reflexes
Tonic neck reflex:
Turning the head
quickly to one side
while infant is in
supine. Arm and
leg extend on that
side. Opposite arm
and leg flex.

Neonatal reflexes
Babinski reflex:
Stroking outer
sole of foot
upward from
heel and across
ball of foot.
Baby fans and
hyper extend
the toes.

Neonatal reflexes
Dolls eye: Turn the newborns head slowly to
one side. Normally eyes do not move.
Certain neonatal reflexes disappear as the
nervous system matures

Care of the neonate

The major goal of the nurse in caring for a neonate
is to establish and maintain homeostasis.

1. Establish and maintain respiration

Clear the mucus in the airways by suctioning
with a bulb syringe.
The oropharynx is to be suctioned first to
prevent aspiration of secretions.

2. Body temperature
At birth, the newborn is wet with amniotic fluid.
Body heat losses by evaporation. To prevent this
dry the newborns skin and hair very well with a
warm soft, dry towel.
The neonate should be wrapped in blankets and
kept close to mothers body or kept under
radiant warmer or heated environment.
The head can be covered with a cap to minimize
heat loss.
The body temperature for normal infants is 36.537.5oC rectally.

3. Prevention of infection
The newborn receives IgA immunoglobulins through
breast milk. The newborn has a poor resistance to
infections.
The babys clothing, linen and equipments should be
clean. Thorough hand washing by all care givers is
essential.
To prevent Ophthalmia neonatorum in high risk infants 12% Silver nitrate 1-2 drops is instilled into the eyes.
The newborn has to receive oral polio and Hepatitis B
vaccinations on the first day.
The umbilical cord area should be washed gently with
water and mild soap. Alcohol can be used to promote
drying. The diaper should be kept below the umbilical
cord exposing it.

4. Prevention of injuries
The new born has to receive 1 mg of Inj. Vitamin
K as IM in vastus lateralis soon after delivery.
While holding the neonate the head and back
should be well supported.

5. Nutrition
Breast feeding should be started within 30
minutes of birth. The signs of hunger are
restlessness, crying, moving the head in search
of food and making sucking movements.
If breast feeding is not possible an infant formula
should be used. Eg. Similac, Aptamil, S26, Nan.
The manufacturers instructions regarding the
dilution should be followed strictly.
Feeding schedule: Self demand feeding. Usually
the newborn takes feeds every 2-3 hours and
sleeps after being fed.

Nutrition
Bubbling
(burping): The
newborn is held
in erect position,
the stomach
pressing on the
mothers
shoulder. The
back is tapped
gently to expel
the swallowed
air.

6. Promoting bonding
Bonding or attachment is the affective bond
between the mother and neonate. Encourage
the mother to take care for the newborn, touch
and talk to the baby while feeding.
Engrossment: Bonding between father and
newborn.
The siblings also should be prepared to receive
the newborn.

Minor problems of the neonate

1.
2.
3.
4.
5.
6.
7.
8.
9.

Physiologic jaundice
Miliaria rubra (prickly heat)
Regurgitation
Constipation
Crying
Subconjunctival hemorrhage.
Caput succedaneum
Precocious teeth
Oral thrush