Assessment Data: Condition of the Infant
Apgar scores at 1 and 5 minutesResuscitative measures Physical examinationVital signsVoidingsPassing of meconium
Care of the Newborn immediately after birth
Maintain respirationsProvide and maintain warmthApgar scorePhysical assessmentNewborn identificationFacilitate attachment
Newborn CarePositioningFeedingEliminationSafety Issues- Newborn identification Newborn abductionBondingCord CareCircumcision Care/Uncircumcision Care
Assessment Data: Infant Complications
Excessive mucusDelayed spontaneous respirations or
responsivenessAbnormal number of cord vesselsObvious physical abnormalities
Assessment Data: Labor and Birth
Duration and courseStatus of mother and fetus Analgesia or anesthesiaProlonged rupture of membranesMeconium-stained amniotic fluidNuchal cord Precipitous birthUse of forceps or vacuum extraction assisted
deviceFetal distress
Assessment Data: Maternal Complications
PreeclampsiaSpottingIllnessRecent infectionsRubella statusSerology resultsHepatitis B screen resultsExposure to group B streptococciHistory of maternal substance Human immunodeficiency virus (HIV) test result
Assessment Data: Family Parents’ interactions with their newborn Their desires regarding infant careInformation about other children in the homeAvailable support systemsPatterns of interaction within each family
unit
Nursing Care: Assessment Airway clearanceVital signsBody temperatureNeurologic statusAbility to feedEvidence of complications
Nursing Care: AssessmentReview of prenatal and birth information Gestational age Newborn’s adaptation to extrauterine lifeWeight and measurementVital signs every 30 minutes Assessment of Hct or blood glucose if
warranted
Daily Assessments Vital signsWeightOverall colorIntake and outputUmbilical cordCircumcisionNewborn feedingAttachment
Daily Newborn Care Assist with feedingsThermoregulationSkin careCord carePrevention of infectionSecurity
Common Concerns How to pick up a newborn Holding and feeding the infantChanging the diaperInterpreting newborn cuesBathing the newbornCord and circumcision careNormal voiding and stooling pattern
Parent Education Periods of reactivity and expected newborn
responsesNormal physical characteristics of the newbornThe bonding processThe infant’s capabilities for interaction The role of touch in facilitating parent-infant
interactionComforting techniquesProgression of infant behaviors Information about available educational
materials and support
Discharge Education Safety measuresVoiding and stool characteristicsCircumcision careCord careWaking and quieting the newborn Car safety ImmunizationsSigns of illness
Signs of Illness Temperature above 38oC or below 36.6oC axillaryContinual rise in temperatureForceful or frequent vomiting Refusal of two feedings in a rowDifficulty in awakening babyCyanosis with or without a feedingAbsence of breathing longer than 20 seconds Inconsolable infant or continuous high-pitched cryDischarge or bleeding from umbilical cord, circumcision, or
any opening Two consecutive green watery or black stools, or increased
frequency of stoolsNo wet diapers for 18 to 24 hoursFewer than 6 to 8 wet diapers per day after 4 days of ageDevelopment of eye drainage