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Nursing Assessment Maternal history/labor data indicating potential problems with newborn
Apgar Scores Findings of brief physical examination performed in the delivery room
Ineffective airway clearance related to nasal and oral secretions from delivery
Ineffective thermoregulation related to environment and immature ability for adaptation
Risk for injury related to immature defenses of the newborn
1. When the head is delivered birth attendant immediately suction secretions Wipe mucus from face
and mouth and nose Aspirate/suction mouth
and nose bulb syringe Keep head slightly lower
than the body
2. Assess airway statusA. Assess for 5 Symptoms of respiratory distress
RetractionsTachypnea (rate: >60 cpm)Dusky color/circumoral cyanosisExpiratory gruntFlaring nares
B. Do not hyperextend neck at anytime (may close glottis)
Place infant in “sniff” position Neck slightly
extended as if sniffing air
Opens airway
3. Immediately dry infant under a radiant warmer or skin to skin contact with the motherKeep neonates
head covered
Infant temperature should be above 36.4°C.
Infants lose heat through evaporation, radiation, conduction and convection.
4. Obtain APGAR Scoring at 1 min and 5 min
Apgar test is a scoring system designed by Dr. Virginia Apgar,
an anesthesiologist, a systematic and measurable
method to access the newborn in the crucial minutes after birth.
Purposes:evaluate the conditions of the baby
at birth, determine the need for
resuscitation, evaluate the effectiveness of
resuscitative efforts, identify neonates at risk for
morbidity and mortality.
Test 0 Points 1 Point 2 Points
Activity (Muscle Tone)
Absent Arms & legs extended
Active movement with flexed arms & legs
Pulse (Heart Rate) Absent Below 100 bpm
Above 100 bpm
Grimace (Response Stimulation or Reflex Irritability)
No Response
Facial grimace
Sneeze, cough, pulls away
Appearance (Skin Color)
Blue-gray, pale all over
Pink body and blue extremities
Normal over entire body – Completely pink
Respiration (Breathing)
Absent Slow, irregular
Good, crying
If there are problems with the infant: an additional score may be repeated at a 10-minute interval.
For a Cesarean section: the baby is additionally assessed at 15 minutes after delivery.
Scoring 7-9 = free from immediate distress; normal 4-6 = moderately depressed; may require
additional resuscitative measures 0-3 = severely depressed; necessitates
immediate medical attention
Note: APGAR score is strictly used to determine the newborn’s
immediate condition at birth and does not necessarily reflect the future health of
your baby.
Scores done at 1 minute to identify who needs immediate intervention.
Scores taken again at 5 minutes to assess recovery from depression or a subsequent turn for the worse.
Resuscitation takes precedence over determining score.
5. Do quick Gestational Age AssessmentA. Sole CreasesB. Breast tissue budC. Skin, vessels, and peelingD. GenitaliaE. Resting Posture
6. Cord Care A. Clamp
umbilical cord approximately 2.5 cm (1 inch) from abdominal wall w/ cord clamp
Examine clamp for closure, no oozing of blood from cord
B. Examine Cord for presence of 3 vessels and document2 arteries and 1 vein
7. Make sure cord blood is collected for analysis and sent to laboratory for checking of: RH Blood type Hematocrit Possible cord blood
gases
8. Document passage of meconium or urine after delivery
For presence of meconium before delvery, mechanical suctioning of naspharynx upon delivery of infant w/ an 8-10 French catheter is done
11.Administer a prophylactic vitamin K Prevent neonatal hemorrhage during first few
days of life before infant is able to produce vit. K Recommended route of administration:
intramuscular Dose:
1mg (of Konakion MM®, 2mg/0.2ml) being given at birth. Preterm infants may receive 0.5mg.
Alternative Route: Oral Dose:
2mg orally at birth; Repeat dose (2mg) at 3-5 days and at 4-6 weeks of
age. Repeat dose if the infant vomits or regurgitates
within 1 hour
12. Bath once a baby's temperature has stabilized, the first bath can be given.
Measure weight, length, and head circumference helps determine if a baby's weight and
measurements are normal for the number of weeks of pregnancy.
Small or underweight babies, as well as very large babies, may need special attention and care.
Average range: 18-22 inches (46-56 cm)
Measured from crown to rump and rump to heel or from crown to heel at birth
Average range: 33 to 35 cm (13-14 inches)Normally, 2 cm larger than chest
circumference Place tape measure above
eyebrows and stretch around fullest part of occiput at posterior fontanele
Average range: 30-33 cm (12-13 inches) Normally, 2 cm smaller than head
circumference
Stretch tape measure around scapulae and over nipple line
Before a baby leaves the delivery area, identification bracelets with identical numbers are placed on the baby and mother.
Babies often have two, on the wrist and ankle.