– communication protocol
– History (for both mother and baby)
– Complete physical assessment which include:
– Vital signs.
– Weighing ,length ,head, arm and chest circumferences.
– General appearance.
– Gestational age .
– Prevention of hemorrhage. (Administer Vit. K if not given in delivery room or mother did not have Vit. K before labor).
– identification bands.
– documentation protocol.
1. initial assessment (Apgar scoring system).
2.Transitional assessment during the periods of reactivity.
3.Systematic physical examination.
Initial Assessment( Apgar scoring system):
– immediate adjustment to extrauterine life
– heart rate
– respiratory effort
– muscle tone
– reflex irritability
Transitional Assessment during the Periods of Reactivity:
– First period of reactivity ( first -30 min):
Baby ( cries, alert, suck afist greedily)
– Physiologically :
respiratory rate ↑ 80 c / min
crackles may be heard
HR ↑ 180 b/ min
bowel sound is active
↑ mucus secretions
↓ temp slightly
Second stage (2-4 hrs) :
– HR → decrease
– respiratory rates → decrease
– Temp → continues to fall
– mucus production → decrease
– urine or stool → not passed
– Sleepy and calm
Second period of reactivity( 2-5 hrs):
– alert and responsive
– heart and respiratory rate → increased
– gag reflex is active
– gastric and respiratory secretions → increased
– passage of meconium
Following this stage is a period of stabilization of physiologic systems
Assessment of gestational age:
– refer to high-risk neonate unit
Systematic physical examination:
– Birth weight: 2700-4000 g.
– Head Circumference: 33-35 cm, about 2-3 cm larger than chest circumference.
– Chest Circumference: 30.5- 33 cm.
– Head to heel length: 48-53cm.
– Axillary: 36.5°C- 37°C.
– Heart Rate:
– Apical 102-140 b/ min.
– 30-60 c/ min.
– Blood Pressure:
– 65/41 mmHg.
Posture ,Skin, Head, Eyes, Ears, Nose, Mouth and throat, Neck
Flexion of head and extremities while rest on chest and abdomen.
At birth →bright red, puffy smooh.
Second to third day →dark pink and dry.
soft with good elasticity and tissue turgor
Edema around eye, face, legs and scrotum or labia
Cyanosis of hands and feet
– soft yellowish cream, which covers the neonates at birth to protect the skin from infection
– It is formed of sebaceous gland mixed with old epithelial cells.
– It may thickly cover the baby or it my be found only in the body crease and between the labia.
– It dries off within 24-48 hours
– long soft growth of fine hair observed on the shoulders, back, extremities, forehead and temples of the neonate
– The more premature baby is, the heavier the presence of lanugo is
– It disappears during the first weeks of life
– black coloration on the lower back, buttocks, anterior trunk and rarely on fingers and feet.
They disappear during preschool years without treatment.
Pealing of the skin occurs within 2-4 weeks of life
Site : nose, knees and elbows
The skin of buttocks should not be left wet or soiled.
– yellowish discoloration of the skin yellowish discoloration
– Appears 2-3 days after delivery
– It is not pathological
– it is associated with excessive destruction of erythrocytes (R.B.C.) that are not needed after birth
– increases for a few days and usually disappears by the 7-10 days.
These are small pinpoint white or yellow spots due to increased fat secretion
Site :nose, forehead, cheeks, and chin of the newborn infants
consist of accumulations of secretions from the sweat and sebaceous glands that have not yet begun to function normally.
ždisappear within a few weeks and it should not be expressed.
– The fontanels are soft spots. Consist of openings at the point of union of the skill bones.
– The anterior fontanel; is diamond in shape and located at the junction of two parietal and frontal bones.
– It is 2-3 cm in width and 3-4 cm in length.
– It closes between 12-18 months of age.
– Fontanels should be flat, soft, and firm. It bulge when the baby cries or if there is increased intracranial pressure.
– Two conditions may appear in the head. These are caput succidaneum and cephalhematoma.
Caput Succidaneum; is edema of the scalp resulting from pressure during labor
Cephalhematoma; is a hemorrhage under the periostieum of one of the cranial bones (usually parietal) resulting from trauma of labor.
Eyes Nursing evaluation
– Lids: Usually edematous.
– Color: Gary, dark blue, brown.
True eyes color is not determined until the age of 3-6 months.
– Pupil: React to light.
– Absence of tears.
– Blinking reflex in response to light or touch.
– Rudimentary fixation on objects
Ears Nursing evaluation
– Position: Top of pinna on horizontal line with outer canthus of eye.
– Startle reflex elicited by a loud sudden noise.
– Pinna flexible, cartilage present.
Mouth and throat Nursing Evaluation
– Intact, high-arched palate.
– Uvula in midline.
– Sucking reflex- strong and coordination.
– Rooting reflex.
– Gag reflex.
– Minimal salivation.