Assessment Data: Condition of the Infant Apgar scores at 1 and
5 minutes Resuscitative measures Physical examination Vital signs
Voidings Passing of meconium
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Apgar Score
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Care of the Newborn immediately after birth Maintain
respirations Provide and maintain warmth Apgar score Physical
assessment Newborn identification Facilitate attachment
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Signs of Newborn Transition
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Neonatal Distress
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Newborn Care Positioning Feeding Elimination Safety Issues-
Newborn identification Newborn abduction Bonding Cord Care
Circumcision Care/Uncircumcision Care
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When to Call for Help
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Assessment Data: Infant Complications Excessive mucus Delayed
spontaneous respirations or responsiveness Abnormal number of cord
vessels Obvious physical abnormalities
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Assessment Data: Labor and Birth Duration and course Status of
mother and fetus Analgesia or anesthesia Prolonged rupture of
membranes Meconium-stained amniotic fluid Nuchal cord Precipitous
birth Use of forceps or vacuum extraction assisted device Fetal
distress
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Assessment Data: Maternal Complications Preeclampsia Spotting
Illness Recent infections Rubella status Serology results Hepatitis
B screen results Exposure to group B streptococci History of
maternal substance Human immunodeficiency virus (HIV) test
result
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Assessment Data: Family Parents interactions with their newborn
Their desires regarding infant care Information about other
children in the home Available support systems Patterns of
interaction within each family unit
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Physiologic Alterations Respiratory distress Pallor Hypothermia
Alterations in feeding and elimination
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Nursing Care: Assessment Airway clearance Vital signs Body
temperature Neurologic status Ability to feed Evidence of
complications
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Nursing Care: Assessment Review of prenatal and birth
information Gestational age Newborns adaptation to extrauterine
life Weight and measurement Vital signs every 30 minutes Assessment
of Hct or blood glucose if warranted
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Daily Assessments Vital signs Weight Overall color Intake and
output Umbilical cord Circumcision Newborn feeding Attachment
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Daily Newborn Care Assist with feedings Thermoregulation Skin
care Cord care Prevention of infection Security
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Cord Care
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Common Concerns How to pick up a newborn Holding and feeding
the infant Changing the diaper Interpreting newborn cues Bathing
the newborn Cord and circumcision care Normal voiding and stooling
pattern
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Parent Education Periods of reactivity and expected newborn
responses Normal physical characteristics of the newborn The
bonding process The infants capabilities for interaction The role
of touch in facilitating parent-infant interaction Comforting
techniques Progression of infant behaviors Information about
available educational materials and support
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Discharge Education Safety measures Voiding and stool
characteristics Circumcision care Cord care Waking and quieting the
newborn Car safety Immunizations Signs of illness
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Wrapping Newborn
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Infant car restraint for use from birth to about 12 months of
age
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Signs of Illness Temperature above 38 o C or below 36.6 o C
axillary Continual rise in temperature Forceful or frequent
vomiting Refusal of two feedings in a row Difficulty in awakening
baby Cyanosis with or without a feeding Absence of breathing longer
than 20 seconds Inconsolable infant or continuous high-pitched cry
Discharge or bleeding from umbilical cord, circumcision, or any
opening Two consecutive green watery or black stools, or increased
frequency of stools No wet diapers for 18 to 24 hours Fewer than 6
to 8 wet diapers per day after 4 days of age Development of eye
drainage
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Documentation of Discharge Teaching How Checking of ID Bands
With whom Condition at discharge Where