Nursing care of the neonate

Nursing care of the neonate

• 1.
  NURSING CARE OFTHE NEONATE NURSING ASSESSMENT Delivery of effective neonatal care is enhanced by communication of pertinent information about the mother and her infant to the pediatrician or other health care provider. It is important that the obstetric staff record the following information on the medical record that accompanies the neonate during any transfer of care. Pertinent Maternal History  Mother's age, socioeconomic status, ethnic or cultural group, educational level, marital status.  Mother's/family's past medical history.  Mother's past obstetric history.  Mother's prenatal history with this pregnancy includes rubella status, hepatitis B testing, history of psychiatric disease, domestic violence, or history of previous child abuse or neglect. Also includes other maternal test results relevant to neonatal care (ie, human immunodeficiency virus test results and colonization with group B-hemolytic streptococci).  Labor and delivery. (Includes intrapartum maternal antibiotic therapy, along with type and dosage of antibiotics.) Physical Assessment Findings and Physiologic Functioning Posture  Full-term neonate assumes symmetric posture; face turned to side; flexed extremities; hands tightly fisted with thumb covered by fingers.  Asymmetric posture may be caused by fractures of clavicle or humerus or by nerve injuries commonly of the brachial plexus.  Infants born in breech position may keep knees and legs straightened or in frog position, depending on the type of breech birth. Length Average length of full-term neonate is 20 inches (51 cm); range, 18 to 22 inches (46 to 56 cm). Weight Average weight of male neonates is 7 ½ lb (3,400 g); female neonates, 7 lb (3,200 g). Weight range of 80% of full-term neonates is 6 lb 5 oz to 9 lb 2 oz (2,900 to 4,100 g). Skin Examine under natural light for:  Hair distribution—term infant will have some lanugo over back; most of the lanugo will have disappeared on extremities and other areas of the body.  Turgor—term infant should have good skin turgor; ie, after gently pinching small portion of skin and releasing it, the skin should return to its original position.  Color
• 2.
  o Cyanosis—acrocyanosis, bluish color in palms of hands and soles of feet, is common because of immature peripheral circulation. This condition is exacerbated by cold temperatures. o Pallor—may indicate cold, stress, anemia, or cardiac failure. o Plethora—reddish (ruddy) coloration may be caused by a high level of RBCs to total blood volume from intrauterine intravascular transfusion (twins), cardiac disease, or diabetes in the mother. o Jaundice—physiologic jaundice caused by immaturity of liver is common beginning on day 2, peaking at 1 week, and disappearing by the 2nd week. It first appears in skin over the face or upper body, then progresses over a larger area; it can also be seen in conjunctivae of eyes. o Meconium staining—staining of skin, fingernails, and umbilical cord indicates passage of meconium in utero (possibly caused by fetal hypoxia in utero).  Dryness/peeling—marked scaling and desquamation are signs of postmaturity.  Vernix—in full-term infants, most vernix is found in skin folds under the arms and in the groin under the scrotum (in males) and in the labia (in females).  Nails—should reach end of fingertips and be well developed in the full-term infant. There should be no evidence of pits, ridges, aplasia, or hypertrophy.  Edema—some edema may occur over buttocks, back, and occiput if the infant has been supine; pitting edema may be caused by erythroblastosis, heart failure, and electrolyte imbalance.  Ecchymosis—may appear over the presenting part in a difficult delivery; may also indicate infection or a bleeding problem.  Petechiae—pinpoint hemorrhages on skin caused by increased intravascular pressure, infection, or thrombocytopenia; regresses within 48 hours.  Erythema toxicum (newborn rash)—small white, yellow, or pink to red papular rash that appears on trunk, face, and extremities; regresses within 48 hours.  Hemangiomas—vascular lesions present at birth; some may fade, but others may be permanent. o Strawberry (nevus vasculosus)—bright red, raised, lobulated tumor that occurs on the head, neck, trunk, or extremities; soft, palpable, with sharp demarcated margins; increases in size for approximately 6 months, then regresses after several years. o Cavernous—larger, more mature vascular elements; involves dermis and subcutaneous tissues; soft, palpable, with poorly defined margins; increases in size the first 6 to 12 months, then involutes spontaneously.  Telangiectatic nevi (stork bites)—flat red or purple lesions most commonly found on the back of the neck, lower occiput, upper eyelid, and bridge of the nose; regress by age 2, although the ones on the neck may persist through adulthood.  Milia—enlarged sebaceous glands found on nose, chin, cheeks, brow, and forehead; regress in several days to a few weeks. They appear as multiple yellow or pearly white papules, approximately 1 mm in diameter. When found in the mouth, they are referred to as Epstein pearls.
• 3.
   Mongolian spots—blue-green or gray pigmentation on the lower back, sacrum, and buttocks; common in Blacks (90%), Asians, and infants of southern European heritage; regress by age 4. May be mistaken for signs of child abuse.  Café-au-lait spots—tan or light brown macules or patches. When less than 1 ¼ inches (3 cm) in length and less than six in number, there is no pathologic significance; if greater than 1 ¼ inches or more than six in number, may indicate cutaneous neurofibromatosis.  Harlequin color change—when on side, dependent half turns red, upper half pale; caused by gravity and vasomotor instability.  Abrasions or lacerations can result from internal monitoring and instruments used at birth.  Cutis marmorata—bluish mottling or marbling of skin in response to chilling, stress, or overstimulation.  Port-wine nevus (nevus flammeus)—flat pink or reddish purple lesion consisting of dilated, congested capillaries directly beneath the epidermis; does not blanch. Head  Examine head and face for symmetry, paralysis, shape, swelling, movement. o Caput succedaneum—swelling of soft tissues of the scalp because of pressure; swelling crosses suture lines. Associated with vacuum-assisted birth. o Cephalohematoma—subperiosteal hemorrhage with collection of blood between periosteum and bone; swelling does not cross suture lines. May result from vacuum-assisted birth (use of the vacuum extractor). o Molding—overlapping of skull bones, caused by compression during labor and delivery (disappears in a few days). o Examine symmetry of facial movements. o Forceps marks—U-shaped bruising usually on cheeks following forceps delivery.  Measure head circumference—13 to 14 inches (33 to 36 cm), approximately ¾ inch (2 cm) larger than chest. Measure just above the eyebrows and over the occiput.  Fontanelles—area where more than two skull bones meet; covered with strong band of connective tissue; also called the soft spot. o Enlarged or bulging—may indicate increased intracranial pressure (ICP). o Sunken—commonly indicates dehydration. o Size—posterior may be obliterated because of molding; generally closes in 2 to 3 months. Anterior is palpable; generally closes in 12 to 18 months.  Sutures—junctions of adjoining skull bones. o Overriding—caused by molding during labor and delivery. o Separation—extensive separation may be found in malnourished infants and with increased ICP. Face  Eyes—examine the following:
• 4.
  o Color—sclerain most full-term infants are white; blue sclera is indicative of osteogenesis imperfecta. Eye color usually slate-gray, brown, or dark blue; final eye color is evident by 6 to 12 months. o Hemorrhagic areas—subconjunctival hemorrhages may appear as a red band from pressure during delivery; regress within 2 weeks. o Edema—edema of the eyelids may be caused by pressure on the head and face during labor and delivery. o Conjunctivitis or discharge—may be caused by instillation of silver nitrate (if still used) or infections from organisms, such as staphylococcus, chlamydia trachomatis, or gonococcus. Tear formation does not usually begin until age 2 to 3 months. o Jaundice—may be seen in sclera because of physiologic jaundice or, if severe, blood-group incompatibility. o Pupils—equal in size and should constrict equally in bright light. o Infant can see and discriminate patterns; limited by imperfect oculomotor coordination and inability to accommodate for varying distances. o Red reflex—red-orange color seen when light from an ophthalmoscope is reflected from the retina. No red reflex indicates cataracts. o Brushfield's spots—white or yellow pinpoint areas on iris that may indicate trisomy 21 or even a normal variant. o Abnormal placement of eyes or small eye openings can signify a syndrome or chromosomal anomaly. o Strabismus—cross-eyed appearance that is common; nystagmus (constant, rapid, involuntary movement of the eye) is also common and disappears by age 4 months.  Nose—examine the following: o Patency—necessary because infants breathe through the nose, not the mouth. o Nasal flaring—abnormal and may indicate respiratory distress. Check for appropriate size and shape of the nose; should be placed vertically midline in face. o Discharge—stuffiness is normal unless chronic nasal discharge is present; may be caused by possible infection. o Sense of smell—infants will turn toward familiar odors and away from noxious odors. o Septum should be midline; low nasal bridge with broad base may be associated with Down syndrome. o Periodic sneezing is common.  Ears—examine the following: o Formation—large, flabby ears that slant forward may indicate abnormalities of the kidney or other parts of the urinary tract. o Position in relation to the eye—helix (top of ear) on the same plane as eye; low- set ears may indicate chromosomal or renal abnormalities. o Cartilage—full-term infant has sufficient cartilage to make the ear feel firm.
• 5.
  o Hearing—auditory canalsmay be congested for a day or two after birth; the infant should hear well in a few days. o Observe for skin tags; preauricular sinus located in front of the ear may be normal or may be associated with genetic disorders.  Mouth—examine the following: o Size—small mouth found in trisomy 18 and 21; corners of mouth turn down (fish mouth) in fetal alcohol syndrome. Mucous membranes should be pink. o Palate—examine hard and soft palate for closure. o Size of tongue in relation to mouth—normally does not extend much past the margin of gums. Excessively large tongue seen in congenital anomalies, such as cretinism and trisomy 21. o Teeth—predeciduous teeth are found on rare occasions; if they interfere with feeding, they may be removed. o Epstein's pearls—small white nodules found on sides of hard palate (commonly mistaken for teeth); regress in a few weeks. o Frenulum linguae—thin ridge of tissue running from base of tongue along undersurface to tip of tongue, formerly believed to cause tongue-tie; no treatment necessary. True congenital ankyloglossia (tongue-tie) is rare. o Sucking blisters (labial tuberales)—thickened areas on midline of upper lip that may be filled with fluid or callous; no treatment necessary. o Infections—thrush, caused by Candida albicans, may appear as white patches on tongue and/or insides of cheeks that do not wash away with fluids; treated with nystatin suspension. Neck Examine the following:  Mobility—infant can move head from side to side; palpate for lymph nodes; palpate clavicle for fractures, especially after a difficult delivery.  Torticollis—appears as a spasmodic, one-sided contraction of neck muscles; generally from hematoma of sternocleidomastoid muscle; usually no treatment required.  Excessive skin folds may be associated with congenital abnormalities such as trisomy 21.  Stiffness and hyperextension may be caused by trauma or infection.  Clavicle—for intactness.  Observe for masses such as cystic hygroma—soft and usually seen laterally or over the clavicle. Chest  Circumference and symmetry—average circumference is 12 to 13 inches (30 to 33 cm), approximately ¾ inch (2 cm) smaller than head circumference.  Breast. o Engorgement—may occur at day 3 because of withdrawal of maternal hormones, especially estrogen; no treatment required. Regresses in 2 weeks.
• 6.
  o Nipples and areolae—less formed and pronounced in preterm infants. Respiratory System  Rate—normally between 30 to 60 breaths/minute; influenced by sleep-wake status, when last fed, drugs taken by mother, and room temperature.  Rhythm—respirations may be shallow with irregular rhythm. o Respiratory movements are symmetric and mainly diaphragmatic because of weak thoracic muscles. For example, the lower thorax pulls in and the abdomen bulges with each respiration. o Periodic breathing—resumption of respiration after 5- to 15-second period without respiration; decreases with time; more common in preterm infants. Substernal retractions, if accompanied by gasps or stridor, are indicative of upper airway obstruction. o Observe for abnormal respiratory signs.  Breath sounds—determined by auscultation. o Bronchial sounds are heard over most of the chest. o Crackles may be heard immediately after birth. o Expiratory grunting is indicative of respiratory distress syndrome (RDS). Cardiovascular System  Rate—normal between 110 to 160 bpm (80 to 110 normal with deep sleep); influenced by behavioral state, environmental temperature, medication; take apical count for 1 minute.  Rhythm—common to find periods of deceleration followed by periods of acceleration.  Heart sounds—second sound higher in pitch and sharper than first; third and fourth sounds rarely heard; murmurs common, majority are transitory and benign.  Pulses—examine equality and strength of brachial, radial, pedal, and femoral pulses; lack of femoral pulses indicative of inadequate aortic blood flow.  Cyanosis—examine for cyanosis. Acrocyanosis of distal extremities is common; record location of any cyanosis, color changes with time, and when crying.  BP—neonates who weigh more than 3 kg (6½ lbs) have systolic BP between 65 and 95 mm Hg; diastolic, between 30 and 60 mm Hg. BP is usually higher in the lower extremities than in the upper extremities. BP assessment may not be conducted routinely on healthy neonates. Measurement of BP is essential for infants who show signs of distress, are premature, or are suspected of having a cardiac anomaly. Abdomen  Shape—cylindrical, protrudes slightly, moves synchronously with chest in respiration.  Distention may be caused by bowel obstruction, organ enlargement, or infection.  Palpate abdomen for masses; gap between rectus muscles is common; palpate liver and spleen.
• 7.
  o Liver has decreased ability to conjugate bilirubin (rationale for physiologic jaundice). o Liver has decreased production of prothrombin and factors that depend on vitamin K for synthesis (rationale for neonate's predisposition to hemorrhage).  Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds occur 1 hour after delivery.  Kidneys—palpate kidneys for size and shape. o Infant has decreased ability of kidney to concentrate urine, excrete a solute load, maintain water and electrolyte balance. o Urine may contain uric acid crystals, which appear on diaper as reddish blotches; uric acid crystals may yield false-positive result when the infant's urine is tested for protein.  Umbilical cord o Normally contains two arteries, one vein; single artery sometimes associated with renal and other congenital abnormalities. o Signs of infection around insertion into abdominal wall-redness, discharge. o Meconium staining—associated with intrauterine compromise or postmaturity. o By 24 hours, becomes yellowish brown; dries and falls off in approximately 10 to 14 days. o Umbilical hernia—defect in abdominal wall.  Genitalia o Female  Labia majora cover labia minora and clitoris in full-term female infants.  Hymenal tag (tissue) may protrude from vagina—regresses within several weeks.  Vaginal discharge—white mucus discharge common; pink-tinged mucus discharge (pseudomenstruation) may be present because of the drop in maternal hormones; no treatment necessary. o Male  Full-term—testes in scrotal sac; scrotal sac appears markedly wrinkled due to rugae.  Edema may be present in scrotal sac if the infant was born in breech presentation; a frank collection of fluid in the scrotal sac is a hydrocele— regresses in approximately a month.  Examine glans penis for urethral opening—normally central; opening ventral (hypospadias); opening dorsally (epispadias); abnormally adherent foreskin (phimosis). o Check for patent anus—infant should stool within 24 hours after delivery. If passed meconium in utero, patent anus has been established. Back  Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus; also for tufts of hair or skin disruptions that would indicate possible spina bifida.
• 8.
   Examine anal area for anal opening, response of anal sphincter, fissures. Musculoskeletal System  Examine extremities for fractures, paralysis, range of motion, irregular position.  Examine fingers and toes for number and separation: extra digits, polydactyly; fused digits, syndactyly.  Examine hips for dislocation—with the infant in supine position, flex knees and abduct hips to side and down to table surface; clicking sound indicates dislocation (Ortolani's sign).  Asymmetrical gluteal folds also indicate congenital hip dislocation.  Examine feet for structural and positional deformities, ie, club foot (talipes equinovarus) or metatarsus adductus (inward turning of the foot). Neurologic System  Neurologic mechanisms are immature anatomically and physiologically; as a result, uncoordinated movements, labile temperature regulation, and lack of control over musculature are characteristic of the infant.  Examine muscle tone, head control, and reflexes.  Two types of reflexes are present in the neonate: o Protective in nature (blink, cough, sneeze, gag)—remain throughout life. o Primitive in nature (rooting/sucking, Moro, startle, tonic neck, stepping, and palmar/plantar grasp)—either disappear within months or become highly developed and voluntary (sucking and grasping). Behavioral Assessment Response to Stimulation  Neonates exhibit predictable, directed responses in social interactions with nurturing adults or in response to attractive auditory or visual stimuli.  Neonate responses are influenced by states of consciousness, such as: o Quiet, deep sleep (sleep state)—no spontaneous activity, eyes closed, respirations regular, with delayed response to external stimuli. o Light, active sleep (sleep state)—random startles, eyes closed, REMs, frequent change of state with response to stimulation. o Drowsy awake (transitional state)—eyes open or closed, appearing dull and heavy lidded, eyelids flutter, variable activity level, mild startles periodically, delayed response to stimulation. o Quiet alert (awake state)—eyes open, little motor activity, focuses on source of stimulation. Interacts most with environment; respirations regular. o Alert active (awake state)—eyes open, less bright and attentive, much motor activity, increase in startles in response to stimulation.
• 9.
  o Crying (awake state)—intense crying that is difficult to interrupt with stimulation; increased motor activity and color changes. Sleeping Pattern  Length of sleep cycles (REM, active and quiet sleep) changes with maturation of the central nervous system (CNS).  Quiet sleep should increase with time in relation to REM sleep.  Neonates usually sleep 20 hours per day. Feeding Pattern  Most neonates eat 10 to 12 times per day with 2 to 4 hours between feedings; establish fairly regular feeding patterns in approximately 2 weeks.  Caloric requirements are high—110 to 130 calories/kg of body weight daily.  Most digestive enzymes are present at birth.  Imperfect control of cardiac and pyloric sphincters; immaturity results in regurgitation. Pattern of Elimination  Stools o Meconium is usually passed in 24 to 48 hours. o Passage of meconium (tarry green-black stools) continues for about 72 hours, followed by transitional stools (greenish brown to yellowish brown; thin; may contain milk curds). Milk stools (for breast-fed, yellow to golden; pasty; odor like sour milk; for formula-fed, pale yellow to light brown; firmer; more offensive odor) are passed by day 4 to 5. o Neonate has up to six stools per day in the first weeks after birth.  Voiding o Neonate voids within first 24 hours. o After first few days, infant voids from 10 to 20 times per day. Temperature Regulation  Infant's body responds readily to changes in environmental temperature.  Heat loss at birth may occur through evaporation, convection, conduction, and radiation.  Physiologic mechanisms to avoid heat loss include: o Vasoconstriction. o Nonshivering thermogenesis elicited by sympathetic nervous system in response to decreased temperature. o Adipose tissue and brown fat—the latter contains many small blood vessels, fat vacuoles, and mitochondria and is a site of heat production. Brown fat is found between scapulae, around neck and thorax, behind sternum, and around kidneys and adrenals.
• 10.
  o Flexed position of full-term neonate. Metabolic Screening Tests  Phenylketonuria—inability of the infant to metabolize phenylalanine; scheduled after 48 hours of protein feedings.  Galactosemia—inborn error of carbohydrate metabolism, in which galactose and lactose cannot be converted to glucose.  Hypothyroidism—thyroid hormone deficiency.  Maple sugar urine disease—inability to metabolize leucine, isoleucine, and valine.  Homocystinuria—inborn error of sulfur amino acid metabolism.  Sickle cell anemia—abnormally shaped RBCs with lower oxygen solubility. Community and Home Care Considerations  The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have established guidelines and have suggested criteria for discharging childbearing women before 48 hours after birth. o Singleton birth between 38 and 42 weeks' gestation. o Mother with uncomplicated vaginal birth and mother and neonate with uncomplicated, antepartum, intrapartum, and postpartum course. o Pertinent laboratory data within normal limits for mother and neonate. o Neonate has spontaneously passed at least one stool and urinated at least once. o Neonate stable, maintaining thermal homeostasis, and feeding well (eg, completed at least two successful feedings with coordinated sucking, swallowing, and breathing). o If circumcised, no excessive bleeding from circumcision site for 2 hours postprocedure. o All necessary vaccines have been administered (eg, hepatitis B) according to current AAP immunization schedules. o Hearing screening has been completed per facility protocol. o Cord or infant blood type and direct Coombs results (if required) have been reviewed. o Family members and support persons are available at home for next several days. o Mother aware of complications for self and neonate. o Facility has in place mechanisms to address patient questions after discharge. o Continuing medical care is planned, usually within 48 hours after discharge and especially for neonates discharged prior to 48 hours after birth.  The first visit at home by the perinatal home care personnel is the longest because a complete physical of mother and the neonate is conducted. Subsequent visits are shorter.  Listening is important. The approach for care is a collaborative one.  Nurse needs to have a thorough knowledge base in: o Normal postpartum and neonatal care.
• 11.
  o Potentialcomplications in the postpartum and neonatal periods. o Nursing interventions for postpartum and neonatal complications.  Personal safety is also a concern. There should be a mechanism in place to locate the home care personnel if needed. Staff should also be trained in actions to take when encountering potentially unsafe situations. It is recommended that home care personnel leave their purse and other pertinent information in their vehicle or at home. Do not carry it on your person should quick escape be necessary. NURSING MANAGEMENT In caring for the neonate, the nurse establishes an ongoing care plan for the infant and the family until discharge. The nurse's assessment of the neonate includes observing and recording vital signs, daily weight gain or loss, bowel and bladder function, activity and sleep patterns, and thermoregulation. Observation for potential problems in the neonate, ensuring safety, and the prevention of infection are main goals of nursing care. PROCEDURE GUIDELINES Newborn Care EQUIPMENT  Cotton balls or disposable washcloths  Neutral soap (varies with facility, but examples include Castile, Dove, and Neutrogena)  70% alcohol  Petrolatum gauze  Protective ointment PROCEDURE Nursing Action Rationale Weight, temperature, and blood pressure 1. Weigh infant and record weight. 1. Newborn may lose 5%-10% of birth weight because of minimal intake of nutrients and fluid and loss of excess fluid. 2. Take axillary temperature by placing2. Use of rectal thermometer predisposes to thermometer in axilla and pressing infant's irritation of rectal mucosa. arm gently but firmly against it for 10 minutes. Prevent undue exposure; provide warm environment (75°-80° F [24°-27° C]). 3. Take blood pressure, if indicated. 3. Hypotension may be present and require remedial action. Bathing technique 1. Use cotton balls or soft, disposable1. Start from cleanest areas to most soiled. washcloths to wipe eyes, face, and outer ears. Eyes are wiped from inside corner outward. 2. Use a neutral soap—check pH. Clear water2. Prevents irritation of skin. The use of
• 12.
  may be usedif infant's skin is dry (bath water hexachlorophene to prevent staphylococcal temperature 98°-100° F [3°-38° C]). infection is controversial. Hexachlorophene may cause brain damage if a sufficient quantity is absorbed through the skin. 3. Wash infant's head, using gentle circular3. Prevents cradle cap from forming, especially motions. over the frontal areas. 4. Tilt head back to cleanse neck. 4. Exposes neck folds for more thorough cleansing. 5. Bathe torso and extremities quickly. 5. Prevents unnecessary exposure and chilling. 6. Carefully dry each area after washing. 6. Prevents heat loss and maintains thermoregulation. 7. Inspect umbilical cord. Check area for7. Minimizes colonization by bacteria. bleeding or foul odor. A drying agent, such as 70% alcohol or merthiolate, may be applied several times daily (according to your facility's policy). Do not cover with diaper. Dressings are not used. 8. Cleanse genital area of male infants. 8. a. Cleanse penis without retracting foreskin. a. Edema and constriction of the penis may result if foreskin is retracted. b.Circumcision care—keep area clean. Place b. Prevents infection and promotes healing. sterile petrolatum gauze over area for first Bleeding can be controlled by pressure or 24 hours; change after voiding. Observe by application of adrenaline solution. hourly for bleeding. Position infant and Prevents discomfort. diaper to avoid friction. 9. Cleanse genital area of female infants. a. Wash vulva from front to back. a. Removes vernix and other discharge. b.Wipe vulva with cotton ball, using one b. Front-to-back cleansing prevents stroke in a front-to-back direction. contamination of vagina. 10.Bathe buttocks, using a gentle, patting10.Area is susceptible to skin breakdown motion. Keep area clean and dry to prevent because of acid reaction of urine and feces. diaper rash. If rash does occur, protective ointment (zinc oxide or A & D) may be used. Exposure of buttocks to air or heat lamp is helpful. Stool observation 1. Observe stool pattern—meconium during1. Material composed of epithelial and first 2 to 3 days. epidermal cells, lanugo, and bile pigments. 2. Transitional stools—change from tarry black2. Changes reflect intake of milk—stools are to greenish black, to greenish brown to composed of meconium and milk stools. brownish yellow to greenish yellow. 3. Number, color, and consistency are recorded3. For early identification of abnormalities. daily. a. No stools within 48 hours indicates an
• 13.
  intestinal obstruction. b. Passage of meconium only (without other stools) suggests obstruction in the ileum. c. Thick, puttylike meconium may indicate cystic fibrosis. d. Diarrhea may be caused by overfeeding or by gastroenteritis. e. Blood in the stools is an indication of intestinal bleeding. Nutritional considerations 1. Provide for nutritional intake. 1. Newborn infants vary in their readiness to feed. 2. Promote feeding method of choice. 2. Although recommendations may be made, family decisions should be respected and continuity of care provided. 3. Test blood glucose using enzymatic strip test3. Newborn may be hypoglycemic and require (according to your facility's policy). feeding sooner than the usual 4- to 6-hour wait. 4. Instruct the parent in technique of bottle-4. feeding. a. Hold infant in semi-upright position. a. Gravity assists flow of milk into stomach. b.Position bottle so that neck of bottle is b. Prevents the infant from swallowing air. filled. c. Insert nipple into infant's mouth so that his c. Sucking and swallowing reflexes are used tongue is under nipple. in feeding. d.Burp during feeding by holding infant d. Allows air to escape from stomach, upright. preventing distention or milk regurgitation. Community and home care considerations 1. Preparation for home care: instruction is1. Instruction for newborn care is a combined given concerning infant bathing and care, responsibility of the medical and nursing preparation of formula, and infant feeding. staffs. Written formula with instructions for preparation is provided to parents. 2. Provide ample opportunity for parent2. Early attachment results in improved contact and care of infant while nursing parent-child relationships. support is available. Take every opportunity to teach. 3. Arrange home visits as necessary. Another main component of caring for the neonate is to assist with establishing a healthy family unit. Because so much of the baby's time is spent with parents, the nurse has the opportunity to assist them with promoting health maintenance by teaching feeding methods and by demonstrating baby care techniques, such as diapering, bathing, and circumcision care.
• 14.
  The nurse provideshealth counseling and education and answers questions to enable the parents to gain confidence, control, and satisfaction in caring for their child at home.