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The
1st 24 hours of Life
The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from
intrauterine to extrauterine life
051104 Neonatal Care 4
Airway & Breathing
• Suction gently & quickly using bulb syringe or suction catheter
• Starts in the mouth then, the nose to prevent aspiration
051104 Neonatal Care 6
Airway & Breathing
• Stimulate crying by rubbing
• Position properly- side lying / modified t-berg
• Provide oxygen when necessary
051104 Neonatal Care 7
Temperature
• Dry immediately
• Place in infant warmer or use droplight
• Wrap warmly
051104 Neonatal Care 8
APGAR Scoring
• Standardized evaluation of the newborn• Perform 1 minute and 5 minutes after
birth• Involves (5) indicators:
1. Activity2. Pulse3. Grimace4. Appearance5. Respirations
051104 Neonatal Care 10
Components• Anthropometric Measurements• Bathing – Oil bath/ warm water bath• Cord Care• Dressing/ Wrapping - mummified• Eye prophylaxis – Crede’s• Foot printing / Identification• Get APGAR score – 1 & 5 mins• HR, RR, Temp, BP• Injection of Vitamin K
051104 Neonatal Care 11
Components
1. Proper identification –tag/bracelet
2. Oil bath/ Warm water bath
3. Cord Care/ Dressing
4. Measurements
1. Weight
2. Anthropometric measurements
051104 Neonatal Care 12
6. Crede’s Prophylaxis
7. Vitamin K Administration
8. Foot printing/ marking
9. Vital signs
10.Dressing/ wrapping
051104 Neonatal Care 13
Proper Identification
• After delivery, gender should be determined
• Pertinent records should be completed including the ID bracelet
• Before transferring to nursery, ID tag should be applied.
051104 Neonatal Care 14
Bathing
• Oil bath or complete warm water bath
• From cleanest to dirties part
• DO NOT remove vernix caseosa vigorously
051104 Neonatal Care 22
Dressing/ Wrapping
• “Mummy”• Wrap in warm
blanket• Cover head with
stockinette cap
051104 Neonatal Care 23
Daily Care
1. Nutrition/ Feeding2. Elimination3. Weight4. Bathing & Hygiene/
Grooming5. Obtain vital signs6. Rooming-in7. Note for any
abnormalities
051104 Neonatal Care 25
Major Time Frames
1. Immediately after birth
2. Within the 1st 4 hours after birth
3. Prior to discharge
051104 Neonatal Care 26
APGAR Scoring System
A ctivity/ Muscle Tone
P ulse/ Heart Rate
G rimace/ Reflex Irritability/ Responsiveness
A ppearance/ Skin Color
R R espiration/ Breathing
1 2 3 4 5
051104 Neonatal Care 27
INDICATORS 2 1 0ActivityActivity Active,
spontaneous Some flexion
of extremities
No movement
(flaccid, limp)
PulsePulse >100 bpm < 100 bpm Absent
GrimaceGrimace Pulls away, sneezes, coughs
Facial grimace only
No response with stimulation
AppearanceAppearance Completely pink Acrocyanosis Bluish-gray or pale all over
RespirationRespiration Good vigorous cry
Slow, irregular
Weak cry
Absent
051104 Neonatal Care 28
Score Interpretation Nursing Interventions
7 to 10 Well baby Rarely needs resuscitation
4 to 6 At risk
INFANT NEEDS INTENSIVE CARE
Requires resuscitation
Suction
Dry immediately
Ventilate until stable
Careful observation
0 to 3 Sick babyPROGNOSIS FOR
NB IS GRAVE
Intensive resuscitation
ET/ Ambu bag
Ventilate with 100% O2
CPR
Maintain body temperature
Parental support
051104 Neonatal Care 29
General Guidelines
• Keep warm during examination
• From general to specific
• Least disturbing first
• Document ALL abnormal findings & provide nursing care
051104 Neonatal Care 31
Posture
• Full term:
– Symmetric
– Face turned to side
– Flexed extremities
– Hands tightly fisted with thumb covered by the fingers
051104 Neonatal Care 32
Special Concerns
• Asymmetric
– Fractured clavicle or humerus
– Nerve injuries (Erb-Duchenne’s Paralysis)
• Breech Presentation
– Knees and legs straightened or in FROG position
051104 Neonatal Care 34
TEMPERATURE
• Site: Axillary NOT Rectal
• Duration: 3 mins
• Normal Range: 36.5 – 37.6 C
• Stabilizes within 8-12 hrs
• Monitor q 30 mins until stable for 2 hrs then q 8 hrs
Heat Loss Mechanisms• Convection – the flow of
heat from the body surface to cooler surrounding air– Eliminating drafts such
as windows or air con, reduces convection
• Conduction – the transfer of body heat to a cooler solid object in contact with the baby– Covering surfaces with a
warmed blanket or towel helps minimize conduction heat loss
051104 Neonatal Care 35
• Radiation – the transfer of heat to a cooler object not in contact with the baby– Cold window surface or
air con; moving as far from the cold surface, reduces heat loss
• Evaporation – loss of heat through conversion of a liquid to a vapor– From amniotic fluid; NB
should be dried immediately
051104 Neonatal Care 36
051104 Neonatal Care 37
Nursing Considerations
• Keep dry and well-wrapped
• Keep away from cold objects or outside walls
• Perform procedures in warm, padded surface
• Keep room temperature warm
051104 Neonatal Care 38
Pulse• Awake: 120 – 160 bpm—120 – 140
bpm
• Asleep: 90-110 bpm
• Crying: 180 bpm• Rhythm: irregular, immaturity of cardiac
regulatory center in the medulla
• Duration: 1 full minute, not crying
• Site: Apical
051104 Neonatal Care 39
Nursing Considerations
• Keep warm
• Take HR for 1 full minute
• Listen for murmurs
• Palpate peripheral pulses
• Assess for cyanosis
• Observe for CP distress
051104 Neonatal Care 40
Special Concerns
• (+) Prominent radial pulse = CHD
• (-) Femoral pulse = Coarctation of aorta
051104 Neonatal Care 41
Respiration
• Characteristics:
Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs) and irregular without cyanosis—periodic respirations
• Rate: 30-60 cpm
• Duration: 1 full minute
051104 Neonatal Care 42
Nursing Considerations
• Position on side
• Suction PRN
• Observe for respiratory distress
• Administer oxygen via hood PRN and as prescribed
051104 Neonatal Care 43
Silverman-Anderson Index
• Perform to observe for signs of respiratory distress
– Chest lag
– Retractions
– Nasal flaring
– Expiratory grunting
051104 Neonatal Care 46
Score Interpretation
Score Interpretation
0-3 No RDS
4-6Moderate RDS
7-10Severe RDS
051104 Neonatal Care 47
Blood Pressure
• NOT routinely measured UNLESS
in distress or CHD is suspected
• At birth: 80/46 mmHg*
• After birth: 65/41 mmHg*
• Using Doppler UTZ
051104 Neonatal Care 49
Body Measurements
• Weight:
– 5.5 to 9.5 lbs (2500-4300 gms)
• Caucasian: 7 lbs
• Filipinos: 6.5 lbs
– 70-75% TBW is water
– LBW = below 2500 gms; regardless of AOG
051104 Neonatal Care 50
• Length:
– 45 to 55 cm (18-22 inches)
– Average: 50 cm
– Techniques: using tape measure
• Supine with legs extended
–Crown to rump
–Head to heel
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• Head Circumference (HC):
– 33 to 35.5 cm (13-14 inches)
– Technique: using tape measure
• From the most prominent part of the OCCIPUT to just above the EYEBROWS
051104 Neonatal Care 52
– 1/3 the size of an adult’s head
– Disproportionately LARGE for its body
– HC should be = or 2cm > CC
051104 Neonatal Care 53
• Chest Circumference (CC):
– 30 to 33 cm (12-13 inches)
– Technique: using tape measure
• From the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly
– CC should be = or < 2 cm than HC
051104 Neonatal Care 55
Nursing Considerations
• Under natural light• Assess for:
–Color–Hair distribution–Turgor/ Texture–Pigmentation/ Birthmarks–Other skin marks
051104 Neonatal Care 56
Skin Color
• Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia
• Pinkish red (light skinned) to pinkish brown to yellow (dark skinned)
• “Ruddy” or reddish due to increased RBC concentration and decreased subQ tissues
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Acrocyanosis
• Bluish discoloration of palms of hands & soles of feet
• Due to immature peripheral circulation
• Exacerbated by cold temperatures
• Normal within 1st 24 hrs
051104 Neonatal Care 60
Pallor/ Cyanosis
• May indicate hypothermia, infection, anemia, hypoglycemia, cardiac, respiratory or neurological problems
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Jaundice• Under natural light
• Blanch skin over the chest or tip of the nose
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• Physiologic
– FT: after the 1st 24 hrs (2-7 days)
– PT:after the 1st 48 hrs
– Peaks at 5-7 days & disappears by the 2nd week
– Due to immaturity of liver
– Usually found over the face, upper body and conjunctiva of eyes
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• Pathologic
– Within 1st 24 hrs
– May indicate early hemolysis of RBC or underlying disease process
– Duration:
• FT: 1 wk
• PT: 2 wks
051104 Neonatal Care 64
Management of Jaundice
• Monitoring serum bilirubin levels – Physiologic: not more than 5 mg/dl
per day– Pathologic: more than 15-20 mg/dl
(critical levels)• Maintain hydration• Place in bilirubin lights as needed• Provide emotional support to parents
051104 Neonatal Care 67
Meconium Staining• Over the skin, fingernails & umbilical
cord
• Due to passage of meconium in utero r/t fetal hypoxia
Lanugo• Found after 20
weeks of gestation on the entire body except the palms & soles
• Fine downy hair that covers the shoulders, back & upper arms
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051104 Neonatal Care 69
Nursing Considerations:
• More mature, less lanugo
• May disappear within 2 weeks
• Preterm: woolly patches of lanugo on skin and head
• Post term: parchment-like skin w/o lanugo
051104 Neonatal Care 70
Vernix Caseosa
• Protective cheesy-like, gray-white fatty substance
• FT: skin folds under the arms and in the groin under the scrotum or in the labia
• Nursing Considerations:– Use baby oil– DO NOT attempt to remove
vigorously
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Desquamation• Dryness/ peeling of the skin
• Usually occurs after 24-36 hours
• Marked scaliness & desquamation = signs of postmaturity
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MiliaMilia• Multiple, yellow or pearly
white papules approx. 1 mm wide
• Due to enlarged or clogged sebaceous gland
• Usually found on the nose, chin, cheeks, eyebrows and forehead
051104 Neonatal Care 75
Mongolian Spots
• Blue-green or gray pigmentation
• Lower back, sacrum & buttocks
• Disappears by 4 years of age
Salmon Patches• Seen commonly in NB• More on Caucasian• AKA: Naevus simplex,
"angel kisses" (when on the forehead or eyelids), and "stork bites" (over the nape of the neck)
• midline malformations consisting of ectatic capillaries in the upper dermis with normal overlying skin.
051104 Neonatal Care 77
051104 Neonatal Care 78
Stork bites
• Telangiectatic Nevi• Flat red or purple
lesions• Back of neck, lower
occiput, upper eyelid and bridge of the nose
• After 2 years of age
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Strawberry marks
• Nevus Vasculosus or Capillary Hemangioma
• Dark red, raised lobulated tumor
• Head, neck trunk & extremities
• After 7 to 9 years of age
051104 Neonatal Care 83
Port-wine stain• Nevus Flammeus or
Capillary Angioma
• capillary malformation
• Flat Red to purple, sharply demarcated dense areas beneath the capillaries
• Face
• Does not fade with time
• Associated with Sturge-Weber syndrome
Sturge-Weber syndrome
• PWS involving the forehead (V1 area of the trigeminal nerve), eye abnormalities (choroidal vascular abnormalities, glaucoma), and leptomeningeal and brain abnormalities (vascular malformations, calcification, or cerebral atrophy)
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051104 Neonatal Care 86
Mottling• Cutis marmorata• reticulated pattern of
constricted capillaries and venules due to vasomotor instability in immature infants
• Bluish mottling or marbling of skin in response to chilling, stress or overstimulation
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Erythema toxicum
• Newborn rash
• Small, white, yellow, or pink to red papular rash
• Trunk, face & extremities
• Within 48 hrs
051104 Neonatal Care 90
Petechiae
• Pinpoint hemorrhages on skin
• Due to increased vascular pressure, infection or thrombocytopenia
• Within 48 hrs
051104 Neonatal Care 91
Ecchymosis
• Bruises• As a result of rupture of
blood vessels• May appear over the
presenting part as a result of trauma during delivery
• May also indicate infection or bleeding problems
051104 Neonatal Care 92
Harlequin Sign
• When on side, dependent side turns red and upper side/ half turns pale
• Due to gravity and vasomotor instability or immature circulation
• Skin resembles a CLOWN’S SUIT
Café-au-lait spots
• Tan or light brown macules or patches
• NO pathologic significance, if <3cm in length and <6 in number
• If > 3 or 6 = Cutaneous neurofibromatosis
051104 Neonatal Care 93
051104 Neonatal Care 96
What to assess
• For symmetry, shape, swelling, movement
–Soft, pliable, moves easily
–With some molding (if VSD); round & well-shaped (if CS)
• Measure HC; HC = or > CC
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• Fontanelles “soft spot”
–BAD (12-18 mos)
–LPT (2-3 mos or 8-12 wks)
–Bulging or sunken
• Sutures
–Overriding or separated
051104 Neonatal Care 98
• Head lag
– Common when pulling newborn to a sitting position
– When prone, NB should be able to lift the head slightly and turn head from side to side
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Caput Succeedaneum
• Swelling of soft tissues of the scalp
• Due to pressure• Crosses the
suture lines• Presenting part• 3 days after birth
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Cephalhematoma
• Subperiosteal hemorrhage with collection blood
• Due to rupture of capillaries as a result of trauma
• Does not crossed suture lines
• Several weeks
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Molding
• Overlapping of skull bones
• Due to compression during labor and delivery
• Disappears in few days
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Forcep Marks
• U –shaped bruising usually on the cheeks after forcep delivery
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Craniotabes
• Localized softening of the cranial bones• Can be indented by pressure of fingers• MOST common among 1st born babies,
pathological in older child—metabolic disorder
• Caused by pressure of the fetal skull against the mother’s pelvic bone in utero
051104 Neonatal Care 107
What to Assess
• Facial movement & symmetry
• Symmetry, size, shape and spacing of eyes, nose and ears
051104 Neonatal Care 108
Eyes
• Color:
– white sclera
– Slate gray, brown or dark blue
– Final eye color: after 6-12 months
• Symmetrical
• Pupils equal, round, reactive to light
• (+) Blink reflex
051104 Neonatal Care 109
• (+) transient strabismus due to weak EOM
• Able to move and fixate momentarily
• (+) Red reflex – if (-), cataract
• (+) Edema on eyelids r/t pressure during delivery or effects of medication
• (-) Tear formation (begins @ 2-3 mos)
051104 Neonatal Care 111
Nursing Considerations
• Administer eye medication within 1 hr after birth to prevent Ophthalmia neonatorum
• DOC: Erythromycin 0.5%Tetracycline 1%Silver Nitrate 1%
• From inner to outer canthus of the eye (conjunctival sac)
051104 Neonatal Care 112
Nose
• Small & narrow
• Flattened, midline
• Nasal breathers
• (+) Periodic sneezing
• Reactive to strong odors
• (+) Flaring = respiratory distress
• (+) Low nasal bridge = Down’s syndrome
051104 Neonatal Care 113
Ears
• Soft and pliable; with firm cartilage Pinna should be at the level of outer canthus of the eye
• (+) Low set ears = renal or chromosomal abnormalities
• May be congested and hear well after few days
051104 Neonatal Care 115
Accessory tragus: remnant of 1st branchial arch
Congenital preauricular sinus:ends blindlyrisk for infection
051104 Neonatal Care 116
Mouth
• Pink, moist gums
• Intact soft & hard palates
– (+) Epstein’s pearls
• Uvula midline
• Tongue moves freely, symmetrical with short frenulum
• (+) Extrusion & Gag reflexes
051104 Neonatal Care 117
• Small mouth or large tongue = chromosomal problems
• (+) white patches on tongue or side of the cheek = Oral thrush
051104 Neonatal Care 118
Neck
• Short, thick, in midline
• Able to flex and extend but cannot support the full weight of head
• Creased with skin folds
• Trachea midline
• Thyroid gland not palpable
• Intact clavicle
051104 Neonatal Care 119
Chest
• CC = or < 2cm than HC
• Cylindrical; equal AP:T diameters
• Symmetrical
• Abdominal breathers
051104 Neonatal Care 120
• (+) Bronchial sounds
• (+) Breast engorgement ; subsides after 2 wks
• (+)Prominent/ edematous nipple
• (+) Accessory nipples
• (+) “Witch Milk”
051104 Neonatal Care 121
Abdomen
• Umbilical Cord– 2 arteries; 1 vein– White & gelatinous immediately after
birth– Begins to DRY between 1-2 hrs
following birth– Blackened or shriveled between 2-3
days– Dried & gradually falls off by 7 days
051104 Neonatal Care 122
Daily Cord Care
• Keep cord dry and clean & clamp secured• Apply 70% isopropyl alcohol to the cord
with each diaper change and at least 2-3x a day.
• DO NOT cover with diaper• Note for any signs of bleeding or drainage
from the cord and other abnormalities• Sponge bath until cord falls off.
051104 Neonatal Care 123
• GIT:– Capacity: 90 ml, with rapid intestinal
peristalsis ( 2 ½ to 3 hrs)– Bowels sounds; (+) within 1-2 hrs
after birth– Presence of mass, distention
depression or protrusion– (+) Scaphoid = diaphragmatic hernia– (+) Distended = LGIT obstruction/
mass
051104 Neonatal Care 124
• Anus
– Check patency
– First stool (Meconium) – within 1st 24 hrs
• Sticky, tarlike, blackish-green, odorless material
051104 Neonatal Care 126
Transitional Stool
• Within 2- 10 days after birth
• Breastfed:
– golden yellow, mushy, more frequent 3-4x and sweet smelling
• Bottlefed:
– Pale yello, firm, less frequent 2-3x, with more noticeable odor
051104 Neonatal Care 127
Nursing Considerations
• Breastfeeding can usually begin immediately after birth
• Bottlefeeding may be started with sterile water to 4 hrs after birth prior to formula feeding
• Burp during and after feeding• Position properly during and after
feeding
051104 Neonatal Care 128
Genitals
• Female:
– Labia: edematous
– Clitoris: enlarged
– (+) Smegma
– Pseudomenstruation possible
– Visible “hymen tag”
– First voiding within 24 hrs
051104 Neonatal Care 129
• Male:– Prepuce covers glans penis
• (+) adherent foreskin = Phimosis– Scrotum: edematous
• (+) enlarged = Hernia– Meatus: central
• (+) ventral/ dorsal = Hypo/epispadias– Testes: descended
• (+) undescended = Cryptorchidism
051104 Neonatal Care 131
Back
• Spine– Straight, posture flexed– Supports head momentarily– Arms & legs flexed– Chin flexed on upper chest– Check for protrusion, excessive or
poor muscle contractions = CNS damage
051104 Neonatal Care 132
Extremities
• Flexed, full ROM, symmetrical
• Clenched fists; flat soles
• With 10 fingers and toes in each hand
• Legs bowed
• Even gluteal folds
051104 Neonatal Care 133
• (+) Creases on soles of feet
– (-) Creases = prematurity
• Check for hip fractures or dysplasia
– (+) Ortolani’s click & uneven gluteal folds = Hip dysplasia
click
!
051104 Neonatal Care 140
Sucking/ Rooting
• Touch the lip, cheek or corner of the mouth
• Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks
• Disappears after 3-4 mos up to 1 year
051104 Neonatal Care 141
Extrusion
• Anything place on the anterior portion of the tongue will be “spit out’
• To prevent swallowing of inedible substances
• Disappears after 4 months
• Disappearance indicates readiness for semi-solid to solid foods
051104 Neonatal Care 142
Swallowing
• Occurs spontaneously after sucking and obtaining fluids
• NEVER disappear
• Newborn swallows in coordination with sucking without gagging, coughing or vomiting
051104 Neonatal Care 143
Tonic Neck/ Fencing
• While the baby is falling asleep or sleeping, gently and quickly turn the head to one side
• As the baby faces the left side, the left arm and leg extend outward while the right arm or leg flex and vice-versa
• Disappears within 3-4 mos
051104 Neonatal Care 144
Palmar(Grasping)/ Plantar
• Place a finger in the palm of the baby’s hand, then place a finger at the base of the toes
• Fingers will curl or grasp the examiner’s finger and the toes will curl downward
• Palmar: fades within 3-4 mos
• Plantar: fades within 8 mos
051104 Neonatal Care 145
Moro
• Hold baby in a semi sitting position then allow the head and trunk to fall backward to at least a 30-degree angle
• Symmetrically abducts and extends the arms; fans the fingers out and forms a C with the thumb and the forefinger; and adducts the arms to an embracing position & returns to a relaxed state
051104 Neonatal Care 146
• Present at birth; complete response at 8 weeks
• MOST significant singular reflex indicative of CNS problem (>6 mos)
• Disappears after 4-5 mos.
051104 Neonatal Care 147
Startle
• Best elicited if baby is 24 hrs old
• Make a loud noise or claps hands
• Baby ‘s arms adduct while elbows flex with fists clenched
• Disappears within 4 mos
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Babinski
• Gently stroke upward along the lateral aspect of the sole, starting at the heel of the foot to the ball of the foot
• Dorsiflexion of big toe and fanning of little toes
• Disappears starts a 3 mos to 1 year• Disappearance indicates maturity of
CNS
051104 Neonatal Care 149
Stepping/ Walking/ Dancing
• Hold baby in a standing position allowing one foot to touch a surface
• Simulates walking by alternately flexing and extending feet
• Disappears after 3-4 mos
Assessment of Gestational Age
• Dubowitz Maturity Scale
– Gestational rating scale
– NB are observed and tested according to the criteria
– Help determine whether the NB needs immediate high-risk nursery intervention
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Usher’s Criteria
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FINDINGS 0-36 WKS 37-38 WKS 39 WKS AND OVER
Sole creases Anterior transverse crease only
Occl creases in ant 2/3
Sole covered with creases
Breast nodule diameter (mm)
2 4 7
Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky
Ear lobe Pliable; no cartilage
Some cartilage Stiffened by thick cartilage
Testes and scrotum
Testes in lower canal; scrotum small; few rugae
Intermediate Testes pendulous, scrotum full; extensive rugae
Ballard’s Scoring
• Completed in 3-4 min
• 2 portions: physical maturity and neuromuscular maturity
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Other Nursing Responsibilities
• Identification band
• Birth Registration
• Birth record and
documentation
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Newborn Screening
051104 Neonatal Care 160
• The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288– The Newborn Screening Act of 2004
• Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days
• Congenital Hypothyroidism (CH)
• Congenital Adrenal Hyperplasia (CAH)
• Galactosemia (GAL)
• Phenylketonuria (PKU)
• Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD Def)
051104 Neonatal Care 161
Disorder Screened If not screened If screened
Congenital Hypothyroidism
Severe mental retardation
Normal
Congenital Adrenal Hyperplasia
Death Alive and Normal
Galactosemia Death or Cataracts Alive and normal
PKU Severe mental retardation
Normal
G6PD Deficiency Severe Anemia, Kernicterus
Normal
051104 Neonatal Care 162
Infant Care Skills
• Holding the baby
– Football Hold
– Cradle Hold
– Shoulder Hold
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Football Hold
Purpose: to carry on one hand free
A holding technique in bathing a baby
Use for small babies
Procedure:
1. slide forearm under his back
2. support neck and head with your hand
3. press his arm firmly against your side
4. his head faces you
5. infant’s feet tucked under your elbow
051104 Neonatal Care 164
Cradle Hold
Purpose: use for feeding and cuddling a baby
Procedure:• support head in the crook of your arm• encircle the body with your arm• press baby firmly against your side• use other hand to support bottom and thigh
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Shoulder Hold
Purpose: use for burping
Procedure:• draw baby towards your chest with one forearm• bracing his back and your hand cradling his head• support your baby’s bottom and thighs with your
other arm• gently press his head against shoulder
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