Newborn

Newborn
Initial Newborn Care and Assessment
ABCs and Temperature ■ Baby should be pink (for dark-skinned Pts, assess oral mucosa, conjunctivae, palms, soles of feet, etc.) and have a loud, vigorous cry. ■ Suction nose and mouth to clear excess secretions, mucus. ■ Stimulate breathing with vigorous rubbing and drying. ■ Dry baby and maintain warmth (wrap in blankets, warmer, etc.). APGAR and Vital Signs ■ Assess and document APGAR at 1 and 5 minutes after delivery. Note: Some hospitals also require a 10-minute APGAR score. ■ Assess and record vital signs (see normal ranges below).
Age	RR	HR	SBP	Temp
Preterm	50–70	140–180	40–60	36.8–37.5_C
Newborn	30–60	120–160	60–90	36.8–37.5_C
Identification ■ Place ID bands on baby and mother. ■ Record baby’s footprints in chart. Measurements ■ Weight: Normal is 6–10 lb. ■ Length: Normal is 18–22 in. ■ Head circumference: Normal is 13–14 in (33–35 cm). ■ Chest circumference: Normal is 12–13 in (30–33 cm). Physical Assessment Note: Perform regular, head-to-toe assessment, similar to an adult, but note the following areas specific to newborn assessment: ■ Appearance: Baby should be pink, have a loud, vigorous cry, and be well flexed with full ROM and spontaneous movements. ■ Fontanels: Anterior is diamond-shaped, ~4 cm at widest point (closes at 7–19 months); posterior is triangular, ≤1 cm at widest point (closes at 1–2 months). ■ Molding: Skull may be oddly shaped with overlapping cranial bones. ■ Mouth: Inspect mouth for cleft lip and/or cleft palate. ■ Heart murmur: Soft murmur considered normal in first few days. ■ Breathing: Abdominal breathing normal in newborns. ■ Umbilical cord: Should have one vein and two arteries. Should be clamped, may or may not be pulsating, and no sign of bleeding. ■ Extremities: Legs and arms equal length to each other and all fingers and toes accounted for. ■ Male genitalia:Testes palpable in scrotum or inguinal canal. ■ Female genitalia: Large labia minora and vaginal discharge of blood or mucus considered normal.
Routine Newborn Medication and Labs
■ Eyes: Eyes medicated with antibiotic ointment according to hospital policy. ■ Vitamin K injection: Given to prevent hemorrhage. ■ PKU (phenylketonuria): Should be obtained 24 hours after feeding begins. Normal serum blood level is <4 mg/dL. Sample is obtained from heel stick using lancet. ■ Coombs’ test: Done if mother’s blood is Rh negative. Determines if mother has formed harmful antibodies against her fetus’ RBCs and transferred them to her baby via placenta. Heel stick sample. ■ Immunizations: Physician may order first hepatitis B vaccine (Hep-B) to be given soon after birth, before discharge

Apgar Score
Appearance (color)	1 min	5 min
■ Pink torso and extremities . . . . . . . . . . 2 ■ Pink torso, blue extremities . . . . . . . . . 1 ■ Blue all over . . . . . . . . . . . . . . . . . . . . . 0
Pulse (heart rate)	1 min	5 min
■ >100 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ■ <100 . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ■ Absent . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Grimace (irritability/reflexes)	1 min	5 min
■ Vigorous cry . . . . . . . . . . . . . . . . . . . . . 2 ■ Limited cry . . . . . . . . . . . . . . . . . . . . . . 1 ■ No response to stimulus . . . . . . . . . . . 0
Activity (muscle tone)	1 min	5 min
■ Actively moving . . . . . . . . . . . . . . . . . . 2 ■ Limited movement . . . . . . . . . . . . . . . . 1 ■ Flaccid . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Respiratory Effort	1 min	5 min
■ Strong loud cry . . . . . . . . . . . . . . . . . . . 2 ■ Hypoventilation, irregular . . . . . . . . . . 1 ■ Absent . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Totals* *8–10, normal 4–6, moderate depression 0–3, aggressive resuscitation