Immediate Care of The Newborn: Establish Respiration and Maintain Clear Airway
Immediate Care of The Newborn: Establish Respiration and Maintain Clear Airway
Immediate Care of The Newborn: Establish Respiration and Maintain Clear Airway
Tangpuz
BSN II
9/21/16
c. The normal infant cry is loud and husky. Observe for the following abnormal cry:
i.
ii.
iii.
4. Oral mucous may cause the new born to choke, cough, or gag during the first 12 to
18 hours of life. Place the infant in a position that would promote the drainage of
secretions.
a. Trendelenburg position head lower than the body
b. Side lying position if the trendelenburg position is contraindicated, place the
infant in side lying position to allow drainage of mucus from the mouth. Place a
small pillow or rolled towel at the back to prevent the newborn from rolling back
to supine position.
5. Keep the nares patent. Remove mucus and other particles that can become the
cause of obstruction.
clotting factors. This makes the new born prone to bleeding. To prevent this, .5 (preterm)
and 1 mg (full term) vitamin K or aquamephyton is injected intramuscularly in the newborns
vastus lateralis.
Care of the cord
The cord is clamped and cut about within 30 seconds after the birth. In the DR, the cord is
clamped twice about 8 in from the abdomen and cut in between. When the new born is
brought to the nursery, another clamp is applied to 1 in from the abdomen and the cord is
cut as the second time. The cord and the area around it are cleansed with antiseptic
solution. The manner of cord care will depend on the protocol of the hospital. Cord clamp
may be taken out after 48 hours when the cord has dried. The cord stump usually just dries
and falls within 7-10 days, leaving a granulating area that heals on the next 7-10 days.
No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that
cord does not get wet by water or urine.
2.
Do not apply anything on the cord such as baby powder or antibiotic, except the
prescribed antiseptic solution which is 70% alcohol.
3.
Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does
not get wet when the diaper soaks with urine.
4.
Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The
cord dries and separates more rapidly if it is exposed to air.
5.
If you notice the cord to be bleeding, apply firm pressure and check cord clamp if
loose and fasten.
6.
Presence of discharge
The cord remains wet and does not fall off within 7 to 10 days
Newborn fever
ASSESS
HEART RATE
Absent
Below 100
Above 100
RESPIRATION
Absent
Slow
Good crying
MUCLE TONE
Flaccid
Some flexion
Active motion
REFLEX IRRITABILITY
No response
Grimace
Vigorous cry
Body pink,
COLOR
Score:
NEWBORN REFLEXES
REFLEX
NORMAL RESPONSE
ABNORMAL RESPONS
E
Head Circumference
34 35 cm
Rooting and
Newborns turns head in direction of
Weak or no response
Temperature
97.6 98.6 F axillary
sucking
stimulus, opens mouth, and begins to
occurs with prematurity,
injury, or central
120 140 bpm
or nipple.
depression secondary to
Respirations
30 60 bpm
Extrusion
Continuous extrusion of
tongue or repetitive
nipple.
Swallowing
Gagging, coughing, or
regurgitation of fluid
tongue.
deficit, or injury;
typically seen after
laryngoscopy.
Bilateral symmetrical extension
and abduction of all extremities, with
thumb and forefinger forming
characteristic C are followed by
adduction of extremities and return to
relaxed flexion when newborns position
changes suddenly or when newborn is
Moro
Asymmetrical response
is seen with peripheral
nerve injury (brachial
plexus) or fracture of
clavicle or long bone or
arm or leg. No response
occurs in cases of
severe CNS injury.
Asymmetrical response
is seen with CNS or
Stepping
Asymmetrical response
is seen with CNS or
Prone crawl
Tonic neck or
fencing
Persistent response
indicate neurologic
injury. Persistent
absence seen in CNS
injury and neurologic
disorders.
Startle
Absence of response
deficit or injury.
noise.
Complete and
consistent absence of
response to loud noises
may indicate deafness.
Response may be
absent or diminished
during sleep.
Weak or absent
Crossed
Extension
on bottom of foot.
Persistent blinking and
Glabellar
failure to habituate
blink
suggest neurologic
deficit.
Response is diminished
in prematurity.
placed in palm of
newborns hand.
peripheral nerve
Palmar grasp
damage (brachial
plexus) or fracture of
humerus. No response
occurs with severe
neurologic deficit.
Plantar Grasp
Diminished response
the toes.