REIMBURSEMENT ISSUES

1

Chapter 27 Care of the Mother and Newborn
2
Overview of Anatomic and Physiological Changes

• Reproductive Organs
• Uterus
• After the delivery of the placenta, oxytocin
  causes the uterus to contract and compress blood
  vessels at the site where the placenta separated
  from the wall this site is 3 to 4 inches in
  diameter.
• If the uterus does not contract adequately, blood
  loss can be excessive.
• Placental site will heal with sloughing of the
  uterine lining this is necessary if more
  pregnancies are to occur.

3
Overview of Anatomic and Physiological Changes

• Reproductive Organs (continued)
• Uterus
• Immediately after delivery, the fundus is about
  midway between the umbilicus and symphysis pubis
  or slightly higher.
• Within 12 hours, it rises to the umbilicus after
  24 to 48 hours, it begins a gradual descent
  within 1 week, the level is at the symphysis
  pubis and barely palpable within 6 weeks, the
  uterus is at the prepregnant state.

4
Figure 27-1, A B
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Mosby.)
A, Normal progress of uterus, days 1 through 9.
B, Size and position of uterus 2 hours after
delivery.
5
Figure 27-1, C D
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Mosby.)
C, Involution of uterus two days after delivery.
D, Four days after delivery.
6
Overview of Anatomic and Physiological Changes

• Reproductive Organs (continued)
• Uterus
• Involution
• Autolysis
• Self-dissolution or self-digestion that occurs in
  tissues or cells by enzymes in the cells
  themselves
• Occurs as a result of withdrawal of estrogen and
  progesterone

7
Overview of Anatomic and Physiological Changes

• Reproductive Organs (continued)
• Uterus
• Lochia fluid waste discharges after delivery
• Lochia rubra
• Bright-red drainage first day or two after
  delivery
• Lochia serosa
• Pink to brown drainage until day 7
• Lochia alba
• Yellow to white drainage continues for an
  additional 10 days to 2 weeks

8
Figure 27-6
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1997. Maternity womens health care. 6th
ed.. St. Louis Mosby.)
Suggested guidelines for assessing lochia volume.
9
Overview of Anatomic and Physiological Changes

• Cervix/Vagina/Perineum
• The cervix will appear edematous, with bruising
  present.
• The external cervical os will have ragged,
  slit-like appearance instead of being round as
  seen in the nulliparous woman.
• The vagina will be thin, with an absence of rugae
  and with dryness present.
• The perineum may have some edema and bruising.
• The episiotomy (if present) should be free of
  erythema, with the edges well approximated.

10
Overview of Anatomic and Physiological Changes

• Cervix/Vagina/Perineum (continued)
• Cervical Injuries
• Injury occurs when the cervix retracts over the
  advancing fetal head.
• It occurs at the lateral angles of the external
  os.
• Most are shallow and bleeding is minimal.
• Extensive lacerations may be a consequence of a
  hasty attempt to enlarge the cervical opening
  artificially or to deliver the fetus before the
  cervix is fully dilated.

11
Overview of Anatomic and Physiological Changes

• Breast
• Estrogen stimulates the growth of milk ducts to
  prepare for lactation.
• The first secretion produced by the breast is
  colostrum?thin, watery, and slightly yellow rich
  in protein, calories, antibodies, and lymphocytes
• Prolactin is responsible for stimulating milk
  production in the mammary alveolar cells.
• Stimulation of nipples, particularly by the
  infants sucking, causes the release of oxytocin
  it also stimulates contraction of the mammary
  ducts and causes milk to be ejected from the
  breast.

12
Figure 27-2
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Mosby.)
Detailed structural features of the human mammary
gland.
13
Figure 27-3
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Mosby.)
Maternal breastfeeding reflexes. A, Milk
production reflex. B, Let-down reflex.
14
Overview of Anatomic and Physiological Changes

• Other Body Systems
• Cardiovascular
• Blood volume is reduced to nonpregnant levels by
  2 to 4 weeks.
• Diuresis
• Diaphoresis
• Blood loss in delivery
• Cardiac output declines rapidly patient is at
  risk for thrombus due to high level of platelets
  in the early postpartum period.

15
Overview of Anatomic and Physiological Changes

• Other Body Systems (continued)
• Urinary
• Possible trauma in delivery and regional
  anesthesia there may be edema of the bladder,
  urethra, and meatus, as well as a decreased urge
  to void.
• Much of the excess blood volume is eliminated
  through diuresis.

16
Overview of Anatomic and Physiological Changes

• Other Body Systems (continued)
• Gastrointestinal
• Appetite returns to normal.
• Gastric motility may continue to decrease,
  leading to constipation.
• Normal bowel elimination should return in 2 to 3
  days.
• Decreased abdominal tone and tenderness resulting
  from episiotomy or hemorrhoids may make the
  patient reluctant to strain for a bowel movement.

17
Overview of Anatomic and Physiological Changes

• Other Body Systems (continued)
• Endocrine
• Placental hormone levels rapidly reduce after
  delivery.
• Estrogen and progesterone levels drop markedly
  following expulsion of the placenta.
• Decreased estrogen levels are associated with
  breast engorgement and diuresis of excess
  extracellular fluid that has accumulated during
  pregnancy.
• Prolactin is secreted only with nipple
  stimulation.

18
Overview of Anatomic and Physiological Changes

• Other Body Systems (continued)
• Musculoskeletal
• Abdominal muscle tone and joint stabilization
  occur during the 6- to 8-week period after
  delivery.
• Some pelvic joints may never return to their
  prepregnant position.
• Discomfort may be felt in the joints immediately
  after delivery because of the hormone relaxin.
• There may be a permanent increase in shoe size.

19
Overview of Anatomic and Physiological Changes

• Other Body Systems (continued)
• Integument
• Changes seen in pregnancy recede, with
  hyperpigmentation gradually disappearing after
  delivery.
• Hair and nail growth returns to normal and skin
  elasticity returns.
• Striae may not fade completely but turns
  silver-gray.
• Diaphoresis is common, especially at night during
  the first week postpartum.

20
Transfer from the Recovery Area

• After the initial recovery period of 1 or 2
  hours, the woman may be transferred to a
  postpartum room.
• Women who have had general or regional anesthesia
  must be cleared from the recovery room by a
  member of the anesthesia care team.
• In some hospitals, the baby stays with the mother
  wherever she goes in others, the baby is taken
  to the nursery for several hours for observation.

21
Nursing Assessment of and Intervention for the
Mother

• Health Perception/Health Management
• Women with uncomplicated deliveries remain in the
  hospital a short time after giving birth.
• It may be only hours, or it may be 1 to 2 days
  after delivery cesarean rarely requires more
  than 5 to 7 days.
• Because early discharge is increasingly common,
  it is important to assess the womans ability to
  meet her own needs and those of her infant.

22
Nursing Assessment of and Intervention for the
Mother

• Health Perception/Health Management (continued)
• Parent-Newborn Relationships
• The mothers reaction to the sight of her newborn
  may range from excited outbursts of laughing,
  talking, and even crying, to apparent apathy.
• Whatever the reaction and cause, the mother needs
  continuing acceptance and support from all of the
  staff.
• Nurses should become knowledgeable about the
  child-bearing beliefs and practices of diverse
  cultural and ethnic groups.

23
Nursing Assessment of and Intervention for the
Mother

• Health Perception/Health Management (continued)
• Promoting Parenting Skills
• Stress that parenthood is a learned role it
  takes time to master, improves with experience,
  and evolves gradually and continually as the
  needs of the parent and child change.
• Through the loving and attentive manner nurses
  exhibit while providing physical care, they act
  as role models.

24
Nursing Assessment of and Intervention for the
Mother

• Nutritional and Metabolic Issues
• Recovery Stage
• The length of time spent in labor, and the
  physical exertion, often result in hunger.
• Fluids are very important during the recovery
  phase to replace the fluids and blood lost during
  delivery.
• The presence of bowel sounds should be verified
  before solid food is given.
• Good oral hygiene should be practiced.
• A complete sponge bath enhances well-being and
  provides comfort.

25
Nursing Assessment of and Intervention for the
Mother

• Nutritional and Metabolic Issues (continued)
• Later Postpartum Stage
• If the woman has not gained an excessive amount
  of weight, prepregnancy weight is normally
  achieved in 6 to 8 weeks without dieting.
• The nonlactating mother should continue to eat a
  well-balanced diet caloric intake should be the
  same as before pregnancy.
• Lactating mothers generally continue with the
  same diet recommended during pregnancy calorie
  intake should increase by 300 to 500 calories per
  day, with daily fluid intake of 2 to 3 liters.

26
Nursing Assessment of and Intervention for the
Mother

• Hygiene
• Good personal hygiene continues to be important
  during the postpartum stage.
• Excessive perspiration and a slight odor from
  discharge are common.
• Regular bathing (shower) should be encouraged.
• Sitz baths are sometimes ordered to reduce
  discomfort and to promote healing of the perineum.

27
Figure 27-5
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Sitz bath.
28
Nursing Assessment of and Intervention for the
Mother

• Elimination
• Recovery Stage
• Diuresis and diaphoresis are common immediately
  after delivery.
• Palpate the bladder for fullness
• Voiding should be encouraged because a full
  bladder may interfere with complete contraction
  of the uterus, potentially causing hemorrhage.
• The initial voiding should be within 4 to 6 hours
  after delivery. Measures to stimulate voiding may
  be required.
• An indwelling catheter may remain in place for 1
  to 2 days after cesarean delivery.

29
Nursing Assessment of and Intervention for the
Mother

• Elimination (continued)
• Later Postpartum Stage
• The nurse must encourage the patient to void
  every 2 to 4 hours.
• If patient is voiding frequently in small
  amounts, the nurse should suspect retention with
  overflow.
• Ask about any symptoms of frequency, urgency, or
  dysuria.
• Review proper cleansing technique after delivery.

30
Nursing Assessment of and Intervention for the
Mother

• Elimination (continued)
• Later Postpartum Stage
• Bowel elimination
• Ideally, elimination should occur before
  discharge.
• Fear of discomfort may result in the patient
  resisting the urge to defecate.
• Bowel peristalsis may be slowed.
• To prevent constipation, many physicians order
  bulk enhancers and stool softeners.
• Occasionally, suppositories are administered to
  promote bowel evacuation.
• Adequate bulk in the diet and fluid intake should
  be stressed.

31
Nursing Assessment of and Intervention for the
Mother

• Elimination (continued)
• Later Postpartum Stage
• Perineal pads, worn to absorb vaginal drainage,
  should be changed after each urination or
  defecation.
• Correct and scrupulous handwashing should be
  stressed to the new mother to prevent
  cross-contamination.

32
Maintenance of Safety

• Activity/Exercise
• Recovery Stage (1 to 4 Hours After Delivery of
  the Placenta)
• Vital signs should be monitored every 15 minutes
  for 2 hours during the recovery stage.
• A patient who has just given birth may need to
  remain in bed for a time to allow the body system
  to adjust to fluid volume changes.
• The nurse will decide the appropriate time for
  the first ambulation.

33
Maintenance of Safety

• Activity/Exercise (continued)
• Recovery Stage (1 to 4 Hours After Delivery of
  the Placenta)
• Orthostatic hypotension tends to occur when a
  woman who has recently given birth stands up.
• Caution the patient to use her call bell to
  summon help before she attempts to get out of
  bed.
• The patient who has received conduction
  anesthesia is kept in bed until she can move legs
  fully and blood pressure and pulse are within
  normal limits.

34
Maintenance of Safety

• Activity/Exercise (continued)
• Later Postpartum Stage
• Vital signs usually stabilize within the first 2
  hours after delivery any abnormalities lasting
  longer should be reported.
• A temperature of 100.4 F or higher on 2
  successive days during the first 10 days after
  delivery is considered indicative of a puerperal
  infection woman is monitored closely.
• Bradycardia may persist up to 10 days following
  delivery elevated or decreased blood pressure
  should be reported.

35
Maintenance of Safety

• Activity/Exercise (continued)
• Later Postpartum Stage
• Activity is needed to prevent complications such
  as thrombophlebitis of the lower extremities.
• The flow of lochia may increase suddenly when the
  patient gets out of bed secretions that pool in
  the vagina drain out of the body when the woman
  stands.
• Postpartum exercises suitable for the new mother
  should begin when the physician identifies the
  appropriate time.

36
Maintenance of Safety

• Rest and Sleep
• Rest and sleep are important throughout the
  postpartum period.
• After the discomforts at the end of pregnancy,
  many women enjoy being able to sleep in any
  position desired.
• Sleep should not be disturbed unless it is
  necessary to protect the patient's well-being.
• If she is breastfeeding, instruct the patient on
  the importance of naps and rest periods during
  the day to compensate for lost sleep.

37
Maintenance of Safety

• Sexuality and Reproductive Issues
• Recovery Stage
• Fundus and lochia are checked every 15 minutes
  for the first 2 hours after delivery.
• Fundus should remain contracted, firm, and at the
  midline this is critical, because severe
  bleeding may result if the uterus does not
  contract the placental site.
• A full bladder can displace the uterus and
  prevent contraction of the uterus encourage the
  patient to empty her bladder before the nurse
  checks the fundus.

38
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Recovery Stage
• An atonic uterus feels soft or boggy the nurse
  may gently massage the fundus to increase
  contractility.
• On palpation of the uterus, the amount of lochia
  should be observed. If the uterus is contracted,
  small to moderate amounts will be seen. If the
  tone is poor, the lochia will increase.
• Always check under the buttocks many times
  gravity causes drainage to miss the pad and pool
  under the patient.

39
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Postpartum checks
• Daily assessments of breasts, fundus, lochia,
  perineum, rectum, and vascular condition of legs
• It is recommended that all new mothers wear a
  bra it should be comfortable and fitted.
• Nonbreastfeeding moms should wear a bra that
  provides adequate compression to inhibit
  lactation without being uncomfortable.

40
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Engorgement
• This uncomfortable fullness of the breasts occurs
  when the milk supply initially comes in.
• It is a result of venous and lymphatic stasis
  that occurs during lactation.
• Filling of the breast with milk usually occurs in
  the axillary regions.
• It is usually seen on the third day postpartum
  and resolves in about 48 hours.

41
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Nipples should be inspected for inflammation,
  fissures, or tenderness.
• If the patient is breastfeeding, nipples should
  be kept soft and supple.
• Avoid the use of soap or other chemicals plain
  water and air drying may prevent problems.
• Modifications in positioning of the baby may
  needed if tender or cracked nipples are a
  problem.
• Assist the breastfeeding mother to be successful
  in establishing lactation.

42
Figure 27-7, A B
(B, Courtesy of Marjorie Pyle, RNC, Lifecircle,
Costa Mesa, California.)
A, Football hold. B, Cradling.
43
Figure 27-7, C D
(C, D, Courtesy of Marjorie Pyle, RNC,
Lifecircle, Costa Mesa, California.)
C, Lying down. D, Across the lap.
44
Figure 27-8
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Mosby.)
Engrossement
45
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Manual pumping of the breasts may be necessary in
  some cases, such as an infant who is unable to
  suckle at the breast or a mother who must spend
  an extended period of time away from her infant.

46
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Benefits of breastfeeding
• There is more rapid involution of the uterus.
• Mother enjoys social closeness with their infant.
• Human milk has antibacterial and antiviral
  properties, immunoglobins, and antiallergy
  factors to protect the infant.
• The milk contains growth factors, digestive
  enzymes, and proteins.

47
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Bottle-feeding is another choice of the newly
  delivered woman.
• Lactation must be suppressed.
• Fundus should remain firmly contracted.
• Lochia may begin to change within the first 2
  days from the rubra to the serosa form.

48
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Have the woman assume a lateral position with the
  upper leg toward the chest.
• Perineum should be approximated if an episiotomy
  was performed, the tissue may appear edematous.
• Most physicians order topical anesthetics such as
  Tucks or Nupercainal ointment.

49
Maintenance of Safety

• Sexuality and Reproductive Issues (continued)
• Later Postpartum Stage
• Hemorrhoids (varicosities of the rectum) usually
  disappear quickly after delivery if there is no
  longstanding history of this problem.
• Topical anesthetics are used to relieve pain.
• Sitz baths also provide relief.
• Homans sign
• Positive indicates inflammation of the blood
  vessels of the leg and possible thrombophlebitis.

50
Psychosocial Assessment

• Coping and Stress Tolerance
• Many new mothers feel overwhelmed by the
  responsibility of motherhood.
• They feel intimidated by the nurses capability
  and skill in taking care of the newborn.
• They often feel inept and may not wish to ask
  questions that might be viewed as unintelligent.
• Establishing a rapport is essential listen for
  fears and anxieties.
• Often women experience a period of depression
  after delivery, triggered by a rapid hormonal
  shift?postpartum depression, or blues.

51
Psychosocial Assessment

• Signs of Potential Problems
• Not all potential psychosocial problems are
  easily identified.
• Some signs may indicate a need for further
  evaluation by a caregiver skilled in that area.
• The presence of one or more of these signs is not
  proof that a problem actually exists.

52
Psychosocial Assessment

• Roles and Relationships
• The mother faces the greatest number of changes.
• She fills the role of primary caregiver to the
  child.
• The loss of freedom to come and go as one pleases
  is difficult.
• Role conflict can lead to guilt and confusion.
• Nurse should be sensitive to the mothers
  concerns.

53
Figure 27-16
(From Gorrie, T.M., McKinney, E.S., Murray, S.S.
1998. Foundations of maternal-newborn nursing.
2nd ed.. Philadelphia W B Saunders.)
Engrossement
54
Psychosocial Assessment

• Roles and Relationships (continued)
• Responsibilities of fatherhood become a reality
  when they see the child they can be frightening.
• Financial concerns of feeding, clothing, and
  sheltering his family take on a new significance.
• The wife is now also a mother, and many times the
  needs of the child will supercede the husbands
  needs or wishes.
• Many men have little knowledge or experience in
  caring for an infant.

55
Psychosocial Assessment

• Self-Perception
• It is common for the new mother to wish to
  discuss her perception of the labor and delivery
  explanations may be needed to clarify things in
  her mind.
• Taking in stage new mother may be somewhat
  passive for the first day or two needs
  supportive care.
• Mood swings are common early in the postpartum
  period, related to current stresses, fatigue, and
  rapid hormonal changes.

56
Psychosocial Assessment

• Cognitive and Perceptual Issues
• Control of discomforts during the postpartum
  period is important.
• Episiotomy pain
• Afterbirth pains cramping sensations
• Most physicians prescribe analgesics for these
  discomforts.
• The new mother needs to know how to care for
  herself and how to care for the newborn teaching
  should be paced throughout the hospital stay.

57
Nursing Process

• Nursing Diagnoses for the Postpartum Mother
• Fluid volume, risk for deficient
• Infection, risk for
• Urinary elimination, impaired
• Constipation
• Nutrition less than body requirements
• Nutrition more than body requirements
• Pain, acute
• Tissue integrity, impaired
• Sleep pattern, disturbed

58
Nursing Process

• Nursing Diagnoses for the Postpartum Mother
• Knowledge, deficient
• Anxiety
• Parenting, risk for impaired
• Family processes, interrupted
• Parenting, impaired
• Self-esteem, situational low

59
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery
• Characteristics
• Body size and shape
• Head is disproportionately large for its body.
• The abdomen is prominent, with a smaller chest
  and narrow hips.
• Average weight 3400 g (7 lbs., 8 oz)
• Average length 20 inches (50 cm)
• Head circumference 13 to 14 inches (33 to 35.5
  cm)

60
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Vital signs
• Respiratory rate 30 to 60 breaths per minute
  with brief periods of apnea
• Pulse rate 120 to 160 beats per minute
• Blood pressure 60 to 80/40 to 50 mm Hg
• Axillary temperature 97.6 F to 98.6 F

61
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately after Delivery (continued)
• Characteristics
• Skin color
• Caucasian pink to slightly reddish
• African-American pink or yellowish brown
• Spanish olive tint or a slight yellow
• Asian rosy or yellowish tan
• American Indian light pink to dark, reddish brown

62
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Skin appearance
• Vernix caseosa yellowish-white cream cheese-like
  substance covering the skin at birth
• Lanugo downy, fine hair, characteristic of the
  fetus between 20 weeks of gestation and birth
• Good turgor and tissue elasticity

63
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Head
• Fontanels should be palpable.
• Head may have molding, caput succedaneum, or
  cephalhematoma.
• Face
• Chin is receding cheeks are full and round oral
  cavity should be intact with a closed palate.
• Epsteins pearls may be observed.

64
Figure 27-10
A, Caput succedaneum. B, Cephalhematoma.
65
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Eyes
• Eyelids may appear edematous.
• Strabismus and nystagmus are commonly seen.
• Nearsighted
• Ears
• Upper insertion of the pinna should be even with
  the outer canthus of the eye.

66
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Umbilical cord
• Whitish blue-gray with three vessels may contain
  a gelatinous tissue called Whartons jelly
• Reflexes
• Rooting, sucking, gag, swallow, blink, burp,
  hiccup, and sneeze

67
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Genitals
• Female may be edematous.
• Scrotum in the male may be enlarged and
  edematous, indicating a hydrocele.
• Penis should be inspected for position of the
  urethral meatus.
• Spine
• Straight without curves

68
Figure 27-11
(Courtesy of Marjorie Pyle, RNC, Lifecircle,
Costa Mesa, California.)
A, Genitals in female term infant. B, Genitals in
male infant.
69
Overview of Anatomy and Physiology of the Normal
Newborn

• Assessment Immediately After Delivery (continued)
• Characteristics
• Extremities
• Arms and hands are generally flexed against the
  body both arms should move evenly.
• Legs should be the same length hips move freely.
• Hands and feet should be assessed for syndactyly
  or polydactyly.

70
Nursing Assessment of and Interventions for the
Newborn

• Health Management and Health Perception
• Check identification bracelets to prevent giving
  the baby to the wrong mother.
• Instruct mother about handwashing when caring for
  the baby.
• Instruct the new mother on safety practices to
  reduce the likelihood of injury to the infant.
• State laws require certain diagnostic tests be
  performed on the newborn phenylketonuria (PKU),
  maple sugar urine disease, glactosemia, and
  hypothyroidism.

71
Nursing Assessment of and Interventions for the
Newborn

• Nutritional and Metabolic Issues
• Nutritional Requirements
• Requires approximately 120 calories per kilogram
  of body weight each day.
• Breast milk and prepared formulas are balanced to
  meet the needs of the newborn.
• Fluid needs 140 to 160 ml/kg per day
• The frequency of feeding will depend on the type
  of feeding.

72
Nursing Assessment of and Interventions for the
Newborn

• Nutritional and Metabolic Issues (continued)
• Hypothermia
• Maintenance of body temperature is a major
  concern when caring for a newborn.
• The newborn has a large surface area and a
  limited amount of protective adipose tissue.
• Heat is lost through radiation, evaporation,
  conduction, and convection.

73
Nursing Assessment of and Interventions for the
Newborn

• Nutritional and Metabolic Issues (continued)
• Hygiene
• Body temperature must be stabilized.
• Bathing serves a number of purposes.
• Provides opportunity for complete cleansing of
  the infant
• Observation of the infants condition
• Promotion of comfort
• Parent/child/family socialization

74
Nursing Assessment of and Interventions for the
Newborn

• Nutritional and Metabolic Issues (continued)
• Hygiene
• The nurse should discuss the choice of cloth or
  disposable diapers with parents.
• Care of the umbilical area avoid getting cord
  wet, use alcohol or other substances to promote
  drying and inhibit microbial growth.
• Circumcision care keep clean and assess for
  bleeding sterile petroleum gauze may be applied
  to the penis.

75
Nursing Assessment of and Interventions for the
Newborn

• Elimination
• Infant should void within 24 hours of delivery.
• Infant usually voids small amounts of poorly
  concentrated urine as the fluid intake increases
  and kidney function improves, urination becomes
  more frequent.
• Bowel elimination should occur within 24 hours of
  birth.
• Initial stools of the newborn are odorless,
  black-green in color, and sticky in
  consistency?meconium.

76
Nursing Assessment of and Interventions for the
Newborn

• Elimination (continued)
• Once the infant begins to take nourishment, the
  stool changes to greenish and loose.
• Breastfed babies tend to pass stool frequently
  it is pale yellow and sweet-smelling.
• The skin of the perineum and buttocks can become
  irritated if waste products are left in contact
  for too long skin should be washed, wiping from
  front to back after each voiding or stool.

77
Nursing Assessment of and Interventions for the
Newborn

• Rest and Sleep
• Infants spend 16 to 20 hours per day sleeping.
• The time awake is spent crying, eating, or in
  quiet alertness.
• Most infants do not exceed 5 continuous hours of
  sleep for some months this can be very
  disruptive to the mothers need for sleep.

78
Nursing Assessment of and Interventions for the
Newborn

• Activity and Exercise
• Maintenance of a clear airway is critical.
• Suctioning may be required to remove mucus from
  the nose and mouth.
• Infants are obligate nose breathers the nasal
  passageway must be kept open and free of mucus a
  small bulb syringe is commonly used.
• Crying is the newborns only means of
  communication it may indicate hunger, pain, or
  simply the need for attention.

79
Nursing Assessment of and Interventions for the
Newborn

• Parent-Child Attachment
• The initial phase in a relationship is
  characterized by strong attraction and a desire
  to interact.
• Without bonding, it would be difficult to
  maintain the energy required to meet the
  newborns needs.
• Early contact with the infant is important to
  establish bonding.
• The nurse should encourage early and frequent
  interaction between the newborn and the parents.