NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: NEWBORN

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Normal Newborn

Focus topic: Maternal–Newborn Nursing

Standard Precautions: All newborns must be handled with gloves until after first bath.

Maternal–Newborn Nursing: Initial Care: Admission/Assessment (0–4 Hours After Birth)

Focus topic: Maternal–Newborn Nursing

A. Assess if resuscitation is needed: clear of meconium; breathing or crying; good muscle tone; color pink; term gestation.
B. Assess respirations, heart rate, and color.

  • Rate < 100 requires positive-pressure ventilation.
  • Rate < 60 requires additional resuscitation efforts (endotracheal intubation, chest compression, medications).

C. Assign Apgar score at 1 minute and 5 minutes.

  • If 5-minute score < 7, additional scores should be assigned q 5 minutes up to 10 minutes.
  • Apgar scoring based on scoring method developed by Virginia Apgar (see Table 12-7).

D. Assess height and weight.
E. Assess temperature (axillary), heart rate (murmurs), respirations and breath sounds, bowel sounds, and capillary refill.
F. Assess for obvious congenital malformations.
G. Check umbilical cord: two arteries and one vein.
H. Obtain head, chest, and abdominal circumference.
I. Observe skin: color, meconium staining, capillary refill; acrocyanosis common for 1–2 hours after birth and when cold.
J. Assess cry: lusty, high pitch, weak.
K. Assess for signs of respiratory distress: tachypnea, nasal flaring, retractions, expiratory grunt, breath sounds decreased.
L. Assess neurological status: reflexes, tremors, twitching.
M. Assess for injuries caused by birth trauma; fractured clavicle, edema of scalp, lacerations, scalp electrode site, dislocated shoulders.
N. Assess for nasal and anal patency.
O. Assess blood glucose when indicated.
P. Complete initial newborn assessment.
Q. Assess gestational age (see Table 12-9).
R. Take vital signs q 30 min, or 1 hr as needed.

  • Assess temperature: > 100°F (37.7°C) may indicate infection or dehydration; < 97.6°F (36.4°C) possibly cold stress, hypoglycemia, temperature instability.
  • Assess pulse, if > 180 or < 100.
  • Assess respirations for indications of respiratory distress.

Maternal–Newborn Nursing: Initial Care: Interventions (0–4 Hours After Birth)

Focus topic: Maternal–Newborn Nursing

A. Every delivery should have at least one person present who is primarily responsible for the baby and who has the skills to initiate resuscitation.
B. There should also be one person immediately available who has the skills to perform complete resuscitation (i.e., endotracheal intubation).
C. If resuscitation is not needed: provide warmth; clear airway with bulb syringe; dry infant; and give baby to mother and/or father to hold.

  • Use warm blankets, hat, or have skin-to-skin contact as infant’s body heat is easily lost.
  • Important to have parents hold infant as soon as possible to promote early bonding.

Maternal–Newborn Nursing

Maternal–Newborn Nursing

Maternal–Newborn Nursing

Maternal–Newborn Nursing

D. If resuscitation is needed, following steps should be done within 1–2 minutes:

  • Provide warmth, usually under radiant warmer in open crib/surface.
  • Position—clear airway as necessary.
  • Dry, stimulate, reposition.
  • Give oxygen as necessary.
  • If heart rate < 100, provide positive-pressure ventilation (PPV).

E. If baby does not begin breathing after being stimulated, he or she is probably in secondary apnea and will require PPV.

  • If heart rate < 60 after initial PPV, consider endotracheal intubation and administer chest compressions.
  • If still < 60, administer epinephrine.
  • Overall goal of initial resuscitation is to ensure the baby’s lungs are ventilated with oxygen.

F. Administer medications within first 4 hours after birth.

  • Apply broad-spectrum antibiotic Ilotycin (erythromycin) or 1% silver nitrate (which is rarely used), within 1 hour after birth to prevent opthalmia neonatorum (blindness from STD).
  • 2. Give vitamin K IM (usually 1 mg), anterior or lateral thigh, for production of blood-clotting factors.
  • Hepatitis B injection if ordered and consent signed by parents (controversial).

G. Check cord clamp is secure and apply if has not been done.
H. Identify baby, mother, and significant other with bands that have the same number.
I. Give initial bath and dress infant when condition and temperature are stable.
J. Care for cord—may use Betadine (povidoneiodine), antibiotic ointment, or alcohol initially.
K. Keep bulb syringe readily available as may accumulate mucus and need suctioning during period of reactivity after deep sleep.
L. Administer feeding as ordered: in some hospitals first feeding is given with supervision (e.g., sterile water), assess for effective swallow, esophageal atresia, etc.

Maternal–Newborn Nursing: Implementation: Normal Newborn

Focus topic: Maternal–Newborn Nursing

A. Monitor vital signs, skin color, newborn assessments, stools, and voids during every shift or per hospital policy.
B. Provide circumcision care following procedure as ordered.

  • Observe for bleeding.
  • Change petroleum gauze as necessary.
  • Keep area clean to prevent infection.
  • Teach parents proper care and signs of infection.

C. Teach parents infant care as needed.

  • Feeding.
  • Holding and burping baby.
  • Cord care.
  • Bath.
  • Diapering.
  • Normal vs. abnormal characteristics, when to call doctor, sleeping, weight loss, stools, interactive behaviors, safety, immunizations, car seats.

D. Teach to prevent infections: proper hand washing, avoiding crowded areas or people with colds.
E. Ensure mother plans follow-up visits to the physician: well baby check, immunizations, phenylketonuria (PKU) testing.
F. If infant has feeding (protein source) in hospital, PKU test can be done while in hospital. If not, arrange appointment for PKU test to be done within 2 weeks of birth.

  • Timing is important to prevent buildup of the amino acid phenylalanine.
  • PKU can result in mental retardation.

Schedules of Newborn Feeding
A. First feeding.

  • May be breastfed immediately following delivery (colostrum is not irritating if aspirated and is absorbed by the respiratory system).
  • Feed in first hour of life.
  • Latest to start feeding is 2–3 hours (when normal low blood sugar occurs).
  • First feeding—many facilities give sterile water, a few swallows to half ounce to evaluate feeding capability. (Glucose water no longer recommended for first feeding due to danger of aspiration pneumonia.)
  • Give full-strength formula or breast milk as soon as newborn shows an interest.

B. Subsequent feeding.

  • Routine schedule: 2- to 4-hour feedings.
  • Self-demand: Baby is fed according to needs, when hungry, usually every 3–4 hours. (Breastfeeding may be 1½–3 hours.)

Calories and Fluid Needs
A. Fluid: 140–160 mL/kg of body weight in 24 hours.

  • Fluid needs are high because the newborn is unable to concentrate urine.
  • More fluids should be given in hot weather or when the baby has an elevated temperature.

B. Caloric needs: approximately 20 kcal/oz formula for term infant or 105–108 kcal/kg/day for newborn.
C. Calorie requirements from the sum of needs for basal metabolic rate (BMR) plus activity, cold stress, loss from feces, digestive and metabolic processes, and growth.

General Infant Assessment
A. Assess vital signs, including pain.

  • Temperature (97.8–99°F/36.6–37.2°C); pulse: 100–160; respirations (30–60/minute); blood pressure somewhat unreliable (80–60/45/40 mmHg).
  • Pain assessment should include behavioral, physiologic/autonomic, and metabolic responses (crying, increased oxygen requirement, increased vital signs, expression, and sleeplessness).
  • Facial features: eye squeeze; brow contraction; taut, quivering tongue and open mouth.
  • Pain in children can be life threatening has more intense, yet shorter response.

B. Assess respiratory status.

  • Infant’s respiratory system must function immediately after loss of placental function; adequate maturation at birth is necessary.
  • 2. From 20–30 mL of fluid are present in the lungs at birth.
    a. Approximately one-third is removed as a result of compression of the chest during delivery.
    b. The remainder is carried off through pulmonary circulation and by the lymph system.
  • Surfactant is a phospholipid found in the lungs.
    a. It reduces surface tension in alveoli and keeps them from collapsing.
    b. Surfactant is necessary to maintain lung expansion and to prevent respiratory distress syndrome.
  • Normal respiration is about 30–60.
    a. Over 60 or below 30 indicates a problem.
    b. Tachypnea is earliest symptom of many neonatal problems (respirations above 60).
    c. Respiration may be slightly elevated during crying episodes or shortly afterward. (Always count for one full minute.)

C. Assess circulatory status.

  • Ductus arteriosus, ductus venosus, and foramen ovale should close (may not be complete for 1 or 2 days).
  •  Peripheral circulation may be sluggish; there may be mottling, acrocyanosis.
  • Heart rate may be variable (normal 100–160).
    a. It may be as high as 180 with crying or below 110 when resting.
    b. Always take apical pulse for one full minute.
  • Skin color/perfusion.
    a. Brisk capillary refill (2–3 seconds).
    b. > 3 seconds indication of hypovolemia.
    c. Color pink (no pallor, dusky, or central cyanosis); note mucous membranes and skin color when blanched; dark-skinned infants may have grayish hue rather than pallor or cyanosis.
  • Anemia is common in early months because of the decrease in erythropoiesis and breakdown of red blood cells.
    a. Baby may need an iron-supplemented formula.
    b. Recommended daily allowance (RDA) for iron is 6 mg/day from birth to 6 months.
    c. Fetal hemoglobin has a shorter life span (80 days).
  • Plethora (red coloring to skin) especially visible when baby cries; may be present due to increase in red blood cells.
  • Physiologic jaundice: normal level less than 1 mg/100 mL blood.
    a. Jaundice visible in skin, sclera.
    b. Begins after first 24 hours of life, usually visible the second or third day after birth.
    c. Caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase, which is needed to convert indirect insoluble bilirubin to directwater-soluble bilirubin that is excreted; transition from fetal to neonatal circulation; and the shorter life span of the fetal RBCs.
    d. Jaundice begins to decrease by the sixth or seventh day.
    e. Should be watched carefully although usually does not require treatment.
  • Clinical jaundice that persists beyond 7 days (term infants) or 14 days (premature infants).
    a. Usual treatment is phototherapy (13 mg/100 mL blood; 15 mg/100 mL in premature infants). If the indirect bilirubin continues to go up, search for cause other than physiologic jaundice is done.
    b. Infant may be on force fluids between feeding to aid in excretion of bilirubin as it is broken down.
  • Transitory deficiency in the ability of the blood to clot.
    a. Bacteria in the intestines are necessary for the production of vitamin K.
    b. Bacteria are not present in the intestines during the first few days after birth newborn infant’s bowel is sterile at birth.
    c. Adequate food and bacteria are necessary to produce vitamin K in the bowel.
    d. Vitamin K IM usually given after birth to aid in blood coagulation.

D. Assess ability of newborn to maintain body heat.

  • 1. Baby suffers loss of heat primarily from head because of being wet and coolness of delivery room.
    a. Place knit cap on head, dry off, and place immediately in a warmer.
    b. Wrap in warm blanket and give infant to mother.
  • Means of heat production in the newborn.
    a. Increasing metabolism.
    b. Shivering is poor in the newborn.
    c. Metabolism of brown fat (less mature infants have less brown fat).
  • Effects of chilling cold stress.
    a. Increased consumption of oxygen.
    b. Use of glucose stored as glycogen.
    c. May become hypoglycemic.
    d. May develop metabolic acidosis products of incomplete metabolism, accumulate with fatty acids from breakdown of brown fat.
    e. Excess fatty acid displaces bilirubin from the albumin binding sites, which can impact jaundice and increase risk of kernicterus.
  • The baby may have a decrease in the production of surfactant.
    a. Glucose, pO2, and proper pulmonary circulation are necessary for the production of surfactant.
    b. Decrease in surfactant may lead to respiratory distress.
  • Temperature may be taken by axilla (rectal not currently a common method).

E. Assess newborn’s weight.

  • Infants usually lose between 5% and 10% of their body weight the first few days, because of low fluid intake and loss of excess fluid from tissue.
  • Usually regain weight lost within 7–14 days.

F. Assess head size and shape.

  • Head or face may be asymmetrical due to birth trauma.
  • Molding of head may be present (elongation of head as it passes through birth canal to accommodate pelvis); usually disappears in about a week.
  • Caput succedaneum: diffuse swelling of soft tissues of scalp, caused by an arrest in circulation in those tissues present over the cervix as it dilates; may cross suture lines.
  • Cephalohematoma: extravasation of blood beneath periosteum of one of the cranial bones because of a ruptured blood vessel during the trauma of labor and delivery; does not cross suture lines.
  • Anterior and posterior fontanel.
    a. Should be open.
    b. Should neither bulge (may indicate intracranial pressure) nor be depressed (may indicate dehydration).
    6. Ears well formed and cartilage present.

G. Assess gastrointestinal system.

  • Salivary glands immature.
  • May have Epstein’s pearls; white raised areas on palate caused by an accumulation of epithelial cells.
  • May have transient circumoral cyanosis.
  • Sucking pads; fatty tissue deposits in each cheek that aid in sucking. They usually disappear when no longer needed.
  • Infant stools.
    a. Meconium plug: thick, gray-white mucus passed before meconium.
    b. Meconium: sticky, black, tarry-looking stools, consisting of mucus, digestive secretions, vernix caseosa, and lanugo; usually passed during the first 24 hours after birth.
    c. Transitional stool: second to fifth day; greenish-yellow color and loose (partly meconium and partly milk).
    d. Breast-fed baby’s stools: formed, non foul-smelling, and more frequent (yellow, golden, pasty).
    e. Bottle-fed baby’s stools: formed, foulsmelling (pale, yellow-light brown).
    f. Observe for color, frequency, and consistency.
  • Regurgitation following feeding is common. It may be reduced by frequent burping during feedings.

H. Assess genitourinary system.

  • Urinary functions.
    a. Observe ability to concentrate urine and check to see if specific gravity elevated.
    b. Uric acid crystals (pink or reddish spot or “brick dust”) may appear on diaper due to high uric acid secretion.
  • Female genitalia.
    a. May have heavy coating of vernix between labia.
    b. Usually has mucus discharge. Mucus may be blood-tinged due to elevated hormonal levels in mother.
  • Male genitalia.
    a. Size of penis and scrotum vary.
    b. Testicles should be descended or in inguinal canal.
    c. Circumcision: surgical removal of foreskin of penis by physician.
    (1) Usually performed by the second or third day.
    (2) Observe for bleeding from postoperative site.

I. Assess skin.

  • Should be pinkish color or consistent with ethnic background, pink-tinged; may appear dry.
  • Acrocyanosis (cyanosis of extremities) may be present for the first hour or two after birth. Persistent blueness may indicate complications such as heart disease.
  • Lanugo and vernix caseosa may be present.
  • Petechiae may be present because of the trauma of birth.
  • Milia (secretions of sebaceous materials in obstructed sebaceous glands) may be present and will disappear.
  • Erythema toxicum neonatorum (small harmless eruptions on the skin); transient in nature.
  • Hemangiomas may be present on nape of neck or upper eyelids.
  • Mongolian spots (bluish pigmented areas present on the buttocks of babies of Asian, African American, or Mediterranean heritage, and other dark-skinned races).
  • Mottling may occur if the infant is chilled.

J. Assess for possible effects of maternal hormones.

  • Maternal hormones may cause enlargement of breast in both male and female infants, and “witches’ milk,” a milklike substance, may be excreted from the breasts.
  • Vaginal bleeding in female infant.
  • Hypertrophy of labia or scrotum.

K. Assess neurological system.

  • Reflexes present at birth (sucking, rooting, Moro, grasp, blinking, yawning, tonic neck, Babinski).
  • Muscle tone.
    a. Fist usually kept clenched.
    b. Baby should offer resistance when change in position is attempted.
    c. Head should be supported when baby is lifted.
    d. Muscles should not be limp.
  • Cry.
    a. Cry should be loud and vigorous.
    b. Baby should cry when hungry or uncomfortable.
  • Hunger.
    a. Usually becomes fretful and restless at 3- to 4-hour intervals.
    b. May suck fingers or anything placed near mouth.
  • Sleep.
    a. Sleeps about 20 out of 24 hours.
    b. Often stirs and stretches while sleeping.

L. Assess functioning of senses.

  • Eyes.
    a. Eyelids may be edematous or have purulent discharge from the chemical irritation of the antibiotic or silver nitrate.
    b. Light perception is present.
    c. Eye movement is uncoordinated.
    d. Usual color of eyes is blue-gray.
    e. May have subconjunctival hemorrhages, which disappear in a week or two.
    f. May gaze at or follow bright objects.
  • Nose.
    a. Newborn breathes through nose.
    b. Sense of smell is present.
  • Ears: Hearing is present at birth.
  • Taste is present at birth.
  • Touch is present at birth. Responds to stimuli and discomfort.

M. Gestational age assessment (using Ballard tool).

  • Assess six neuromuscular and six physical characteristics during the first few hours of life. Total score is correlated with weeks of gestation (total of 35 points correlated with 38+ weeks’ gestation).
  • Rating is then plotted on graph against weight, length, and head circumference to classify infant’s gestational age characteristics and physical growth, which then confirms infant’s status as appropriate (10th–90th percentile), small (< 10th percentile) or large (> 90th percentile) for gestational age.
  • Maturity.
    a. Neuromuscular maturity may be unstable during first 24 hours and may need to be repeated. Characteristics include: posture, square window, arm recoil, popliteal angle, scarf sign, and heel-to-ear extension.
    b. Physical maturity is not influenced by labor and birth and does not change significantly. Characteristics observed include: skin, lanugo, plantar surface creases, breast tissue, eye/ear recoil, genitalia (males testes descended, scrotum; females labia tissue).

N. Immunity factors.

  • May receive from the mother some passive immunity to infectious diseases, such as measles, mumps, and diphtheria.
  • Capacity to develop own antibodies is slow during first few months.
  • Has little resistance to infection.
  • Immunizations: If mother is a carrier both hepatitis B vaccine and hepatitis B immune globulin (HBIG) should be given within 12 hours of birth.

Maternal–Newborn Nursing: General Implementation

Focus topic: Maternal–Newborn Nursing

A. Maintain body temperature.

  • Place infant in heated incubator or crib with radiant heat.
  • Wipe off fluid, mucus, and excessive vernix.
  •  Avoid excessive exposure.
  • Wrap infant in warm blankets.
  • Transfer to the nursery after parents have seen and held infant (or as per hospital protocol).

B. Maintain respiration.

  • Place infant on side, in modified Trendelenburg position, to prevent cerebral edema and to facilitate drainage of mucus and blood.
  • Suction mucus as needed with bulb or suction catheter attached to mucus trap.
  • Provide oxygen as needed.

C. Prevent infection and injury.

  • Eye care.
    a. To prevent eye infections (opthalmia neonatorum) from gonorrhea or chlamydia.
    b. Most common treatment: broadspectrum antibiotic ointment applied to eyes (e.g., Ilotycin [erythromycin] ointment or Sumycin [tetracycline]).
    c. May use 1% silver nitrate (rarely used): two drops in conjunctival sacs; flush eyes with water after about 2 minutes; not effective against chlamydia and can cause chemical conjunctivitis.
  • Cord care use sterile scissors and clamp. Apply sterile water or air dry as ordered (triple dye or antimicrobial agent such as bacitracin used less often).
  • Never handle newborn baby without wearing gloves until after first bath with antibacterial soap observe Standard Precautions.

Maternal–Newborn Nursing: Newborn HIV Positive or AIDS

Focus topic: Maternal–Newborn Nursing


Focus topic: Maternal–Newborn Nursing

A. Transmission can occur during utero via the placenta, through breast milk or contaminated blood.
B. Maternal to newborn transmission rate (20–30% of mothers with HIV) decreases by ⅔ when treated with antiviral (Retrovir [zidovudine] antepartal, intrapartal, and to newborn).
C. Tests for newborn antibodies may not show until up to 15 months after birth.


Focus topic: Maternal–Newborn Nursing

A. Assess for physical signs: enlarged spleen and liver, swollen glands.
B. Assess for recurrent respiratory infections, rhinorrhea, interstitial pneumonia, recurrent gastrointestinal problems, failure to thrive, opportunistic infections, developmental delays.


Focus topic: Maternal–Newborn Nursing

A. Don gloves and gown to protect self from contamination. Use Standard Precautions.
B. Wait until newborn’s temperature is stable in the nursery to provide care.
C. Wash infant carefully with antibacterial soap wearing gloves and gown.
D. Administer cord care with sterile water or air dry as ordered (alcohol, iodine solution, or antibacterial ointment used less often).
E. Wrap infant in clean blanket.
F. Dispose of gloves and gown in plastic bag.
G. Teach principles of care to mother of HIV baby.

  • Breastfeeding is discouraged when mother tests positive for HIV.
  • Circumcisions are not done on infants with HIV-positive mothers until infant’s status is determined.
  • Immunizations with live vaccine (oral polio, measles–mumps–rubella [MMR]) should not be done until infant’s status is confirmed. If infant is infected, live vaccine will not be given. Inactivated polio vaccine (IPV) will be administered.
  • Excellent hygiene procedures should be carried out in the home.
  • Inform the caregiver exposed to infant’s body fluids of the potential for infection transmission.
  • Teach the importance of good hand hygiene techniques.
  • Facilitate referral to community agencies and support groups as needed. Mother often unable to assume care because of own illness.

Maternal–Newborn Nursing




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