NSG210 Durham Ch. 15: Nursing Care of the Neonate and Family

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 15, pp. 481-529 (textbooks/DURHAM_OB_CH15.pdf, also in textbooks/exam03/ and textbooks/exam04/). Week 10 reading (OB lecture on October 28 covers newborn transition and assessment); also assigned in the Week 14 online module (“newborn assessment”), so it may appear on Exam 3 and Exam 4. Lecture slides: raw/nsg210_wk10_OBLecture4.md (Newborn Transition, Initial Newborn Assessment, S.T.A.B.L.E., Maturity Assessment, Medications for Newborns, Cold Stress, Circumcision). High-risk neonatal conditions (RDS, jaundice, sepsis) are in nsg210-durham-ch17-complications-of-neonate; feeding is in nsg210-durham-ch16-newborn-nutrition.

Learning Outcomes

1. Identify changes in the transition from intrauterine to extrauterine life and related nursing actions.
2. List critical elements of neonatal assessment and gestational age assessment.
3. Discuss neonatal pain management.
4. Plan nursing care for the first week of life.
5. Explain common neonatal laboratory and diagnostic tests.
6. Support parents in newborn care; describe therapeutic and surgical procedures (circumcision, immunizations).
7. Incorporate cultural beliefs and newborn variations; educate parents.

Nursing diagnoses: risk for hypothermia (little subcutaneous fat, large surface area); risk for infection; risk for impaired gas exchange (circulatory transition, cold stress, mucus); knowledge deficit (first-time parents).

Outcomes: temperature normal, skin pink and warm; no infection; normal HR and RR with clear airway; voids and stools at least 3 times a day by day 3; parents demonstrate care and list warning signs.

I. Overview

• Neonatal period: birth through the first 28 days
• Nursing focus: maintain cardiorespiratory function and body heat, reduce infection risk, watch for complications, support nutrition, educate parents

II. Transition to Extrauterine Life

A. Respiratory system

• First breaths are the first and most critical change
• Triggers: chemical (mild hypoxia, low pH, high PCO2 at birth stimulate the medullary respiratory center), mechanical (thoracic squeeze in the birth canal clears some fluid; recoil causes passive inspiration), sensory (drying, temperature change, sound, light, touch, skin-to-skin)
• Crying raises intrathoracic pressure and helps clear lung fluid
• Lung fluid cleared in most term newborns within 4 hours; SpO2 rises above 90% within 5 to 15 minutes
• Oxygenation dilates pulmonary vessels and lowers pulmonary vascular resistance (PVR)
• Surfactant keeps alveoli open and maintains functional residual capacity
• Two factors that impair transition: low surfactant (immature lungs) and severe or persistent hypoxemia and acidosis (PVR stays high)
• About 10% of neonates need some help breathing at birth; 1% need extensive resuscitation

Critical Component, signs of respiratory distress: central cyanosis, tachypnea, apnea, grunting, nasal flaring, chest wall retractions, hypotonia (late sign).

B. Circulatory system

• Cord clamping raises systemic vascular resistance (SVR); breathing lowers PVR
• Ductus venosus (umbilical vein to IVC, bypasses liver): closes when cord flow stops; permanently closed within 2 weeks, becomes a ligament
• Foramen ovale (right to left atrium): closes when left atrial pressure exceeds right; functionally closed within 1 to 2 hours, permanently by 30 months. Hypoxia and high PVR can reopen it
• Ductus arteriosus (pulmonary artery to aorta): closes within 15 hours in most term infants and by 96 hours in nearly all; permanent within 3 months. Can stay open or reopen with poor lung expansion, hypoxia or high PVR

C. Thermoregulation

• Neutral thermal environment (NTE): maintains temperature with minimal oxygen use and metabolic rate
• Newborn responses to cold: higher metabolic rate and oxygen use, increased muscle activity (restless, crying, flexed), peripheral vasoconstriction (mottling, acrocyanosis, pallor), metabolism of brown adipose tissue (BAT)
• Nonshivering thermogenesis = BAT metabolism. BAT is dense and vascular; located in the neck, thorax, axillae, between the scapulae, around the adrenals and kidneys. Term infants have large amounts; preterm infants little. Depleted quickly by cold stress
• Newborns CANNOT SHIVER; high surface-area-to-mass ratio, little subcutaneous fat, high metabolic rate

Four mechanisms of heat loss (Fig. 15-4):

• Evaporation: moisture on skin vaporizes (right after birth, bathing). Prevent by drying immediately
• Conduction: direct contact with a cooler surface (cold hands, cold scale). Prevent by warming hands, equipment, blankets
• Convection: cooler air currents (air conditioning, oxygen mask). Prevent by closing doors, keeping away from vents, warming oxygen, stocking cap
• Radiation: transfer to cooler objects NOT in contact (cold isolette walls, outside windows). Prevent by keeping away from outside walls and windows, preheating warmers

Cold stress (Fig. 15-5): cold raises metabolic rate, oxygen use and glucose use, leading to hypoxia, hypoglycemia, metabolic acidosis, decreased surfactant, respiratory distress, possible return to fetal circulation, increased bilirubin and jaundice, poor feeding, apnea and death.

• Risk factors: prematurity, SGA, hypoglycemia, prolonged resuscitation, sepsis, neurologic, endocrine or cardiorespiratory problems
• Signs: axillary temperature below 97.7 F (36.5 C), cool skin, restlessness or crying, pale or mottled skin, acrocyanosis, tachypnea, grunting, hypoglycemia, hypotonia, lethargy, jitteriness, weak suck

Prevention: dry immediately, remove wet blankets, stocking cap, skin-to-skin with a warm blanket over both, prewarmed blankets and warmers, warm the stethoscope, delay the first bath until temperature is stable, bathe under a radiant heat source, keep away from vents, drafts, outside walls and windows.

Treatment of cold stress: stocking cap; skin-to-skin or warm swaddling; correct the environment; recheck temperature about every 30 minutes until stable; heel stick for glucose (below 40 to 45 mg/dL is hypoglycemia); if still below 97.7 F, place undressed (diaper only) under a PREHEATED radiant warmer with the servo probe on the abdomen; warmer set about 1.5 C above the infant’s temperature and adjusted; monitor temperature, RR and HR every 5 minutes while rewarming; notify the provider if temperature does not normalize.

D. Metabolic system and hypoglycemia

• Glycogen and fat stored in the third trimester for the transition
• Glucose is lowest in the first hours and rises over 12 hours: 40 to 60 mg/dL on day 1 after the first 4 hours; 50 to 90 mg/dL after day 1
• Hypoglycemia: blood glucose below 40 to 45 mg/dL
• Infants of diabetic mothers keep high insulin after birth, causing hypoglycemia
• Risk factors: infant of a diabetic mother, LGA, post-term, late preterm, preterm, SGA, hypothermia, infection, respiratory distress, resuscitation, birth trauma
• Signs: jitteriness and tremors, irritability, tachypnea, grunting, seizures, apnea, hypotonia, lethargy, hypothermia, cyanosis, poor feeding
• Nursing: monitor signs; check glucose; breastfeed or formula feed; buccal dextrose gel if the mother does not want formula or hypoglycemia persists; IV dextrose requires NICU admission; maintain NTE; recheck glucose 30 minutes after feeding

E. Hepatic system

• Immature liver affects carbohydrate metabolism, clotting, bilirubin conjugation, vitamin and iron storage, and drug detoxification
• Vitamin K deficiency bleeding: vitamin K is made by intestinal flora, which are absent at birth; needed for factors II, VII, IX, X. A single prophylactic dose within the first hour
• Bilirubin: indirect (unconjugated, fat-soluble) from RBC breakdown is converted by the liver to direct (conjugated, water-soluble) for excretion in urine and stool. Hyperbilirubinemia comes from immature liver function, high RBC count and short fetal RBC life span; occurs in most term and nearly all preterm infants; usually benign, but pathological jaundice can cause permanent neurologic damage. AAP: screen all neonates before discharge
• Stores vitamins A, D, E, K and iron (iron from destroyed RBCs is used when RBC production resumes)
• Immature detoxification raises the risk of drug toxicity

F. Gastrointestinal system

• Bowel sounds within the first hour
• Stomach capacity about 5 mL/kg (15 to 24 mL in most term infants); colostrum intake 2 to 10 mL per feed on day 1, 30 to 60 mL per feed by day 4; emptying time 2 to 4 hours
• Breast milk digests faster: breastfed every 2 to 3 hours, formula-fed every 3 to 4 hours
• Stools:
  • Meconium: sticky, thick, greenish-black, odorless; first passed within 24 to 48 hours
  • Transitional: starts around day 3 for 3 to 4 days; black to greenish-brown to yellow
  • Breastfed: yellow, semiformed, later golden, pasty, “seedy,” sour odor
  • Formula-fed: firmer, paler or brownish yellow, unpleasant odor
  • Diarrheal: loose, watery, green

Table 15-1, minimum wet diapers and stools:

G. Renal system

• Low GFR at birth (doubles by 2 weeks): risk of overhydration and water intoxication; limited ability to concentrate urine (dehydration); electrolyte disorders (hypo- and hypernatremia in preterm infants); drug toxicity
• Urine output 15 to 60 mL/kg/day the first few days; 250 to 400 mL/day by the end of month 1
• Normal weight loss 5% to 10% in the first week (partly diuresis)
• Maternal magnesium sulfate can delay or decrease urination

H. Immune system

• Immature; slower inflammatory response; signs of infection are subtle and nonspecific; a sick newborn tends to become HYPOTHERMIC rather than febrile
• First exposure usually from the maternal genital tract (group B strep, E. coli)
• IgG: crosses the placenta; temporary passive immunity
• IgA: does not cross the placenta; in colostrum and breast milk
• IgM: made by the fetus in response to intrauterine infection (TORCH: toxoplasmosis, rubella, CMV, syphilis, varicella, herpes, Zika); maternal IgM does not cross
• Passive immunity (from mother) is temporary; active immunity develops after exposure or vaccination

III. Neonatal Assessment

• Apgar, vital signs and general survey at birth; full head-to-toe within 2 hours; gestational age if indicated
• Reduce heat loss during assessment: warm draft-free room, radiant warmer or assess in the parent’s arms, expose only the area being checked
• Review prenatal and birth records for risk factors: late or no prenatal care, substance use, maternal age under 16 or over 35, diabetes or hypertension, preterm birth, forceps or vacuum, CNS-depressing drugs in labor (magnesium sulfate, analgesia, anesthesia)
• General survey while quiet: observe breathing and auscultate heart and lungs FIRST (before the infant cries), skin color, alertness, tone and posture
• Physical exam usually head to toe, but noninvasive parts first

Table 15-2 highlights (expected findings for a term neonate):

Table 15-3, common newborn characteristics:

• Acrocyanosis: blue hands and feet from immature circulation or cold; normal
• Central cyanosis: around mouth, mucous membranes, torso; may occur in the first 10 minutes but NEVER assume normal after that
• Mottling: benign pink and white blotches from cold
• Harlequin sign: half the body pink, half white (vasomotor instability)
• Slate gray patches: flat bluish areas on the back or buttocks (more common in Black, Asian, Hispanic and Native American infants); may be mistaken for bruising, so document size and location; fade by school age
• Erythema toxicum: red macules and papules with white-yellow centers, mostly trunk, within 24 hours up to 2 weeks; benign
• Milia: white papules on nose and chin (sebaceous glands); leave alone
• Lanugo: fine hair after 16 weeks, decreases toward term; abundant in preterm
• Vernix caseosa: white cheesy coating; less at term (axillae, groin)
• Jaundice: yellow skin starting at the head and moving down; assess in natural light by blanching over the nose, forehead or sternum. Within 24 hours = pathological (blood type incompatibility, sequestered blood); after 24 hours usually physiological
• Molding: elongated head; resolves within 1 week
• Caput succedaneum: scalp EDEMA from pressure against the cervix; spongy; CROSSES suture lines; resolves within the first week
• Cephalhematoma: BLOOD between periosteum and skull from prolonged labor, forceps or vacuum; appears within hours and may enlarge; well defined; does NOT cross sutures; can contribute to jaundice; resolves within 3 months
• Epstein pearls: white cysts on gums and palate; benign
• Natal teeth: often loose; usually removed (aspiration risk); may be associated with congenital defects

Table 15-4, newborn reflexes:

IV. Gestational Age Assessment

• New Ballard Score (NBS): 6 physical and 6 neuromuscular criteria; estimates down to about 20 weeks, accurate within 2 weeks
• Commonly done for: preterm (under 37 weeks), post-term (over 42 weeks), weight under 2,500 g or over 4,000 g, infants of diabetic mothers, NICU admissions, no or inadequate prenatal care, ROM over 24 hours, meconium-stained fluid, placental abnormalities, 5-minute Apgar 7 or below
• Classification: preterm under 37 weeks, term 37 to 42, post-term over 42; SGA under 10th percentile weight, AGA 10th to 90th, LGA over 90th

Neuromuscular criteria (more mature = more flexion and resistance):

• Posture: more flexion of arms and legs
• Square window: wrist flexes closer to the forearm
• Arm recoil: faster return to flexion
• Popliteal angle: smaller angle
• Scarf sign: elbow does NOT cross midline
• Heel to ear: heel stays farther from the ear

Physical criteria:

• Skin: thin, translucent with visible veins (preterm) to thicker, peeling, cracked (mature)
• Lanugo: abundant in preterm, thinning, bald areas at term
• Plantar creases: develop from the ball of the foot toward the heel; more creases = more mature
• Breast: stippled to full areola with 5 to 10 mm bud
• Eye and ear: fused lids in very preterm; ear stiff with thick cartilage and instant recoil at term
• Male genitals: testes descending, more rugae with maturity
• Female genitals: labia majora cover the minora and clitoris with maturity (preterm: prominent clitoris)

V. Pain Assessment and Management

• Neonates feel pain and may be hypersensitive; untreated pain has short- and long-term effects
• Tools: Premature Infant Pain Profile (PIPP), Neonatal Infant Pain Scale (NIPS); look at arousal state, cry, movement, breathing, facial expression, HR, BP, SpO2

Critical Component, pain prevention and treatment (combinations work better than single methods):

• Swaddling; facilitated tucking (flexed position close to the caregiver)
• Non-nutritive sucking (pacifier); breastfeeding; skin-to-skin; infant massage; gentle talking and stroking
• Heel warmers before blood draws
• Oral sucrose or glucose
• Opioids (morphine, fentanyl), benzodiazepines (lorazepam, midazolam), acetaminophen, NSAIDs, local or regional anesthetics (lidocaine)
• Evidence-based practice: 30% oral sucrose plus non-nutritive sucking 2 minutes before a heel stick lowered PIPP scores more than either alone

VI. Behavior

Periods of reactivity (first 6 to 8 hours):

• First period (birth to 30 to 40 minutes): alert, active, responsive; the “golden hour” for skin-to-skin and breastfeeding. RR up to 80, HR up to 180; increased secretions and crackles; transient grunting, flaring and retractions; brief central cyanosis; bowel sounds absent
• Relative inactivity (starts 30 to 40 minutes after birth, lasts 2 to 4 hours): deep sleep; HR and RR fall, may be slightly below normal; fewer secretions; bowel sounds heard
• Second period (lasts 2 to 8 hours): alternates active and quiet alert; rapid breathing and HR with stimulation; another good time to breastfeed

Infant states (2 sleep, 4 awake): deep sleep (no movement except startles, hard to wake), light sleep (most of sleep; REM, easier to wake), drowsy, quiet alert (eyes wide, most attentive, best for interaction), active alert (fussy, responds to disturbing stimuli), crying.

Brazelton Neonatal Behavioral Assessment Scale (not routine): habituation (decreased response to repeated stimuli, a protective mechanism), orientation, motor maturity, self-quieting (sucking on hand), social behaviors. These are diminished with prematurity, CNS injury or drug exposure.

VII. Nursing Care in the Fourth Stage of Labor (Birth to 4 Hours)

• Review records for risks (prolonged ROM: infection; meconium: respiratory distress; diabetes: hypoglycemia)
• Dry and stimulate by rubbing the back; clear mouth and nose with a bulb syringe if needed
• Apgar at 1 and 5 minutes
• Vital signs within 30 minutes, at 1 hour, then hourly in recovery; every 5 to 15 minutes if distressed
• Oxygen per protocol if HR under 100, low SpO2, central cyanosis or apnea
• Prevent heat loss (dry, warm dry blankets, cap, skin-to-skin or preheated warmer)
• Wear gloves until after the first bath
• Inspect the cord for number of vessels and bleeding
• ID bands on infant and parents BEFORE any separation
• Weigh and measure; full assessment within 2 hours; gestational age per policy; glucose for at-risk or symptomatic infants
• Erythromycin eye ointment and vitamin K IM within 1 hour of birth
• Support breastfeeding; cluster care, dim lights, close the door; notify the provider of birth time and findings

Critical Component, promoting attachment: assessments can be done in the parent’s arms if the infant is term with Apgar 8 or higher and no distress; skin-to-skin with a warm blanket; point out normal characteristics; private time; DELAY EYE OINTMENT until parents have held the baby (ointment blurs vision and reduces eye contact); respect cultural beliefs.

Critical Component, danger signs to report: RR over 60, grunting, nasal flaring, retractions, abdominal distention, seizures, lethargy, jaundice in the first 24 hours, abnormal or unstable temperature, jitteriness, persistent hypoglycemia, no meconium within 48 hours, no void within 24 hours.

Bathing: delay at least 6 to 24 hours and until temperature is stable at 98.2 F (36.8 C) or above; late preterm infants 12 to 24 hours. Evidence-based practice: delaying the bath 24 hours increased exclusive breastfeeding at discharge (hypothermia and hypoglycemia were lower but not significantly).

VIII. Nursing Care From 4 Hours to Discharge

• Vital signs and assessment at least once per shift (more for late preterm)
• Promote parent and sibling attachment
• Infant abduction prevention: footprints and photo; matching ID bands on infant, mother and partner checked every shift and whenever the infant is moved; security tags that alarm, lock doors and freeze elevators within 4 feet of an exit; unit-specific staff badges; parents never hand the baby to anyone without the badge; never leave the baby alone in the room (even while showering); locked units
• Assist with feeding; teach safe sleep (back, no bed-sharing)
• Skin care: assess each shift and at diaper changes; change diapers and clean with water or wipes every 1 to 3 hours; petrolatum or zinc oxide barrier for at-risk infants (no need to remove completely; no vigorous rubbing); minimize adhesives and remove slowly with moist gauze

IX. Medications and Procedures

Erythromycin ophthalmic ointment 0.5%: prevents gonococcal and chlamydial ophthalmia neonatorum; 1 cm ribbon in the lower lid of each eye within 1 hour; do not let the tip touch the eye; side effects: lid edema and inflammation.

Phytonadione (vitamin K, AquaMephyton): prevents vitamin K deficiency bleeding; activates factors II, VII, IX, X; 0.5 to 1 mg IM within 1 hour of birth; side effects: injection site redness, pain, swelling.

Hepatitis B vaccine: before discharge for all newborns. If the mother is HBsAg positive or the infant may have been exposed: hepatitis B vaccine AND hepatitis B immune globulin (HBIG) within 12 hours. Second dose at 1 to 2 months; third at 6 to 18 months.

Critical Component, IM injection: explain and invite parents; consent if required; 1 mL syringe with a 25-gauge 5/8-inch needle; VASTUS LATERALIS; clean off maternal blood and amniotic fluid; stabilize the knee; 90-degree angle; immunizations do not require aspiration; document.

Critical Component, heel stick: warm the heel 5 to 10 minutes (not always needed for glucose); gloves; dorsiflex the foot; alcohol and let dry; puncture the LATERAL or MEDIAL aspect of the heel (avoid nerve damage); wipe off the first drop; collect large drops; bandage; document.

X. Screening Tests

• Genetic disease screen (GDS, blood spot): about 30 disorders (varies by state); within 24 to 48 hours and again around day 5; heel stick
• Phenylketonuria (PKU): cannot metabolize phenylalanine (in breast milk and formula); buildup causes brain damage and death; preventable with early detection and diet
• Hearing screen: loss in 1.6 per 1,000; done before discharge in a quiet room when calm or asleep; vernix, blood or fluid in the ear interfere; rescreen in 1 month if failed; diagnostic testing if failed twice
• Hyperbilirubinemia screen: universal before discharge; interpret by age in hours on a nomogram (Bhutani); transcutaneous meter (on the sternum) or serum bilirubin; visual estimates not recommended, especially in darkly pigmented infants. Occurs in 60% of term and 80% of preterm infants; extreme levels cause acute bilirubin encephalopathy or kernicterus
• Critical congenital heart defect (CCHD) screen: pulse oximetry after 24 HOURS of age on the RIGHT HAND (preductal) and EITHER FOOT (postductal). Pass: 95% or higher in either extremity with a difference of 3% or less. Detects hypoplastic left heart, pulmonary atresia, tetralogy of Fallot, transposition of the great arteries, and many pulmonary problems
• Hypoglycemia screening for high-risk infants (diabetic mother, SGA, LGA, preterm, post-term)

XI. Circumcision

• Elective removal of the foreskin; parents decide based on culture, religion and information; AAP says benefits outweigh risks but does not recommend it routinely
• Benefits: fewer UTIs in the first year; lower risk of HIV and STIs; less balanitis, phimosis, paraphimosis; lower risk of penile and prostate cancer
• Contraindications: preterm infants, genitourinary defects (hypospadias), bleeding risk, compromising illness (RDS)
• Risks: hemorrhage, infection, adhesions, pain
• Devices: Gomco clamp, Mogen clamp (used by mohels), Plastibell
• Pre-op: teaching, written consent, verify the infant has VOIDED and has no anatomic abnormality; acetaminophen 1 hour before if ordered; gather equipment and anesthetic
• Intra-op: circumcision board; bulb syringe at hand; penile nerve block; sucrose-dipped pacifier
• Post-op Gomco or Mogen: petroleum gauze or generous petroleum ointment on the penis (and diaper) at each change for 1 to 2 weeks; heals within 2 weeks
• Post-op Plastibell: NO lubricant (can dislodge the ring); ring falls off in a few days to a week; do not pull it off
• Check for bleeding every 15 minutes for the first hour, then every 2 to 3 hours; report bleeding larger than a quarter; acetaminophen every 4 to 6 hours; must void within 24 hours

Parent teaching: red glans with yellow crusts is normal healing (do not wash off); check for bleeding every 4 hours for 24 hours; do not pull off gauze; diaper not too loose or tight; call for bleeding larger than a quarter, whole penis red, warm, swollen or draining, or no void within 24 hours.

XII. Parent Education

• Bathing: every few days (daily soap irritates); immersion or swaddled immersion preferred (less heat loss); mild pH-neutral soap, none on the face; water 100 to 104 F (37.7 to 40 C); 5 to 10 minutes; never leave alone; clean to dirty; eyes inner to outer with a clean corner for each eye; dry hair right away; front to back for girls; pat dry
• Bulb syringe: compress before inserting; mouth first (sides, roof, back), nose only if secretions visible; release slowly; clean with soapy water
• Clothing: diaper, shirt and loose outfit indoors; sun protection; avoid overbundling (SUID risk). Overheating signs: sweating, damp hair, red skin or heat rash, rapid breathing, restlessness
• Cord care: diaper folded below the cord; clean with plain water if dirty and pat dry; alcohol not needed; clamp off at 24 hours; falls off and heals within 2 weeks; report bleeding, foul drainage, redness, fever
• Crying: little in the first 2 weeks, peaks about 2 to 3 hours/day at 6 weeks, about 1 hour/day by 12 weeks
• Colic: cries at least 3 hours a day, 3 days a week, for at least 3 weeks in a healthy infant (“rule of 3s”); diagnosis of exclusion; loud high-pitched paroxysmal cry, grimacing, legs drawn up or back arched; keep a diary. Soothing: sway or walk, pacifier, swaddle, belly-down across the knees with back rubs, bouncer, car ride, near a running dryer or vacuum, stroller walk
• Critical Component, colic (AAP): deep breath and count to 10; put the baby in a safe crib and leave the room for 10 to 15 minutes; calm yourself; check without picking up until calm; call the doctor or a friend; NEVER shake, throw or hit
• Diaper dermatitis: change every 1 to 3 hours by day and at least once at night; superabsorbent disposables; water or wipes without scrubbing; petroleum or zinc oxide at the first sign; avoid powder, cornstarch and antibiotic ointments; breast milk may help
• Diapering: ankle hold; wipe front to back; do not retract an uncircumcised foreskin; fold the diaper below the cord
• Elimination: at least 6 wet diapers a day by day 6; brick-dust urates normal in the first days but report if in more than 2 diapers after that (dehydration); pseudomenstruation normal; report runny green stools, fewer than 6 wet diapers after day 6, constipation
• Follow-up: newborn visit 48 to 72 hours after discharge (AAP: 2 to 4 days); then 1, 2, 4, 6, 9 and 12 months. Growth spurts at 14 days, 3 weeks, 6 weeks, 3 months, 6 months (fussier, feeds more)
• Jaundice: starts at head and face and moves to chest, abdomen, limbs and sclera; check gums and inner lips in darker-skinned babies; call if very yellow, very sleepy or hard to wake, feeding poorly, very fussy, fewer wet or dirty diapers, or dry mucous membranes
• Pediatric abusive head trauma (shaken baby syndrome): injury in children under 5 from blunt impact or violent shaking; 1,200 to 1,400 cases a year, mostly at 3 to 8 months; leading cause of death under age 2; up to 25% fatal; 65% of survivors have neuro impairment. Crying is the usual trigger. Teach how shaking injures the brain and eyes, crying patterns, coping strategies, and that it is OK to leave the baby safely in the crib for 10 minutes; ask for help; parental stress lines
• Safe sleep (AAP): BACK for every sleep (side is unsafe); stop swaddling when the infant starts trying to roll (about 2 months); firm flat surface with a fitted sheet; no soft objects, toys, loose bedding or bumper pads (use sleep sacks); no sleeping in adult beds, couches or chairs (bed-sharing); room-share in the parents’ room for at least 6 months; no smoking, alcohol or drugs; breastfeeding and pacifiers protect (offer pacifier after breastfeeding is established, do not reinsert if it falls out); avoid overheating; immunizations protect; avoid products claiming to prevent SIDS; supervised tummy time daily (prevents plagiocephaly). SUIDs have dropped almost 50% with safe sleep
• Safety: small objects, strings and plastic bags out of reach; bath water 100 to 100.4 F; water heater 120 F or lower; never leave in the tub; locked unloaded guns; pool barriers; no cooking or hot drinks while holding the baby; supervise pets; crib sides fixed; outlet covers. Falls: never leave on an elevated surface or a car seat on a table; stair gates; wide-based high chair. Poisoning: chemicals and medicines up high; cabinet latches; remove lead paint
• Car seats: required from the day of discharge; back seat until age 12; REAR-FACING until 2 to 3 years or the seat’s height or weight limit; certified child passenger safety technicians (seatcheck.org); never leave a child alone in a car
• Siblings: prepare during pregnancy; sibling classes; visit in the hospital; gift “from the baby”; one-on-one time and outings; explain crying. Regression (wetting, wanting a bottle) and hitting are common
• Skin: bathe every few days; pH-neutral cleansers; avoid adhesives and perfumed products; petroleum ointment sparingly on dry skin (not head or face)
• Soothing: feed, reposition, talk or sing, swaddle, hold close, rock or walk, pacifier, stroller
• Swaddling: shoulders at the fold; arms down or flexed with hands near face; legs bent up and out with room for hip movement (prevents hip dysplasia); 2 to 3 fingers fit between chest and blanket; stop around 2 months or when trying to roll
• Temperature: axillary (hold the arm against the side until it beeps) or rectal (most accurate; lubricate, no more than 0.5 inch); tympanic not recommended under 6 months; if high, remove extra clothing and recheck in 15 to 20 minutes

When to call the provider: rectal temperature above 100.4 F (38 C) or axillary above 99 F (37.2 C); poor appetite or refusing feeds; lethargic, not waking to feed; weak or no cry; watery green stools; vomiting; fewer wet diapers; rash; sunken or bulging fontanels; bleeding or foul odor from the cord or circumcision.

High-Yield Numbers

• Neonatal period: first 28 days
• Lung fluid cleared within 4 hours; SpO2 over 90% by 5 to 15 minutes
• Foramen ovale functionally closed 1 to 2 hours; ductus arteriosus 15 hours (96 hours nearly all); ductus venosus permanent within 2 weeks
• Cold stress below 97.7 F (36.5 C); normal axillary 97.7 to 99 F
• Hypoglycemia below 40 to 45 mg/dL; normal day 1 40 to 60, after 50 to 90
• RR 30 to 60; HR 110 to 160; BP 50-75/30-45
• Apnea over 20 seconds is abnormal; periodic pauses up to 15 seconds normal
• Head 32 to 36 cm; chest 2 to 3 cm smaller; length 46 to 52 cm; weight 2,500 to 4,100 g
• Weight loss 5% to 10%, regained by 10 to 14 days; evaluate feeding if over 7%
• Anterior fontanel closes by 18 months; posterior by 2 to 4 months
• Void within 24 hours; meconium within 24 to 48 hours; 6 or more wet diapers by day 6
• Stomach 5 mL/kg; colostrum 2 to 10 mL per feed day 1
• Eye ointment and vitamin K (0.5 to 1 mg IM) within 1 hour; HBIG within 12 hours if exposed
• Bath delayed 6 to 24 hours; temperature at least 98.2 F
• CCHD screen after 24 hours: 95% or more and 3% or less difference
• Colic: 3 hours, 3 days, 3 weeks
• Rear-facing to 2 to 3 years; room-share 6 months; water heater 120 F or lower

Priority Nursing Actions and Red Flags

• Dry immediately; prevent all four kinds of heat loss; preheat warmers
• Cold stress leads to hypoglycemia and respiratory distress; check glucose in any cold or jittery infant
• Jittery infant: check glucose first; feed if low
• Central cyanosis after 10 minutes, grunting, flaring, retractions or RR over 60: report
• Jaundice in the first 24 hours is pathological
• No void in 24 hours or no meconium in 48 hours: report
• Bulging fontanel at rest: increased ICP; sunken: dehydration
• Sick newborns become hypothermic, not febrile
• Asymmetric Moro after shoulder dystocia: check the clavicle and brachial plexus
• ID bands before separation; never hand the baby to unbadged staff
• Back to sleep; no bed-sharing; no soft bedding
• Never shake a baby; plan for coping with crying
• Plastibell: no petroleum; Gomco or Mogen: petroleum at each change
• Femoral pulses weaker than brachial: possible CHD

Medications

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• INDEX