Maternal & Child Nursing Care

Maternal & Child Nursing CareFourth editioN

Marcia L. London • Patricia A. Weiland Ladewig • Michele R. Davidson Jane W. Ball • Ruth C. McGillis Bindler • Kay J. Cowen

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Pearson Global Edition

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For these Global Editions, the editorial team at Pearson has collaborated with educators across the world to address a wide range of subjects and requirements, equipping students with the best possible learning tools. This Global Edition preserves the cutting-edge approach and pedagogy of the original, but also features alterations, customization, and adaptation from the North American version.

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# 110506 Cust: Pearson Education / NJ / CHET Au: London Pg. No. 1 Title: Maternal-Newborn & Child Nursing Care 4e Server:

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Maternal & Child Nursing Care

Marcia L. London, RN, MSN, APRN, CNS, NNP-BCSenior Clinical Instructor and Ret. Director of Neonatal Nurse Practioner Program

Beth-El College of Nursing and Health Sciences, University of Colorado, Colorado Springs, Colorado

Patricia A. Wieland Ladewig, RN, PhDProvost

Regis University, Denver Colorado

Michele R. Davidson, RN, PhD, CNM, CFNAssociate Professor of Nursing and Women’s StudiesCoordinator of the School of Nursing PhD Program

George Mason University, Fairfax, Virginia

Jane W. Ball, RN, CPNP, DrPHConsultant

American College of Surgeons, Gaithersburg, Maryland

Ruth C. McGillis Bindler, RNC, PhDProfessor Emeritus

Washington State University, College of Nursing, Spokane, Washington

Kay J. Cowen, RN-BC, MSNClinical Professor

University of North Carolina at Greensboro School of Nursing, Greensboro, North Carolina

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References 575

ReferencesAssociation of Women’s Health, Obstetric and Neonatal

Nurses (AWHONN). (2005, reaffirmed 2009). Clinical position statement: Universal screening for hyperbilirubinemia [Position statement]. Washington, DC: Author.

Blackburn, S. T. (2013). Maternal, fetal, & neonatal physiology: A clinical perspective (4th ed.). St. Louis, MO: Saunders.

Brazelton, T. B., & Nugent, J. K. (2011). The neonatal behavioral assessment scale (4th ed.). London, England: MacKeith.

Cheffer, N. D., & Rannalli, D. A. (2011). Transitional care of the newborn. In S. Mattson & J. E. Smith (Eds.), Core curriculum for maternal-newborn nursing (4th ed., pp. 345–361). St. Louis, MO: Saunders.

Cloherty, J. R., Eichenwald, E. C., Hansen, A. R., & Stark, A. R. (2012). Manual of neonatal care (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Furdon, S. A., & Benjamin, K. (2010). Physical as-sessment. In M. T. Verklan & M. Walden (Eds.),

Core curriculum for neonatal intensive care nursing (4th ed., pp. 121–155). St. Louis, MO: Saunders.

Gardner, S. L., & Goldson, E. (2011). The neonate and the environment: Impact on development. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, & J. A. Hernandez (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care (7th ed., pp. 270–331). St. Louis, MO: Mosby.

Lauderdale, J. (2012). Transcultural perspectives in childbearing. In M. M. Andrews & J. S. Boyle (Eds.), Transcultural concepts in nursing care (6th ed., pp. 91–122). Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins.

Luchtman-Jones, L., & Wilson, D. B. (2011). The blood and hematopoietic system. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff & Martin’s Neonatal- perinatal medicine (9th ed., pp. 1308–1373). St. Louis, MO: Elsevier-Mosby.

Manco-Johnson, M., Rodden, D. J., & Hays, T. (2011). Newborn hematology. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, & J. A. Hernandez (Eds.),

Merenstein & Gardner’s handbook of neonatal intensive care (7th ed., pp. 503–530). St. Louis, MO: Mosby.

McGrath, J. M., & Hardy, W. (2011). The infant at risk. In S. Mattson & J. E. Smith (Eds.), Core curriculum for maternal-newborn nursing (4th ed., pp. 362–414). St. Louis, MO: Saunders.

Niermeyer, S., & Clarke, S. (2011). Delivery room care. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, & J. A. Hernandez (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care (7th ed., pp. 52–77). St. Louis, MO: Mosby.

Raab, E. L., & Kelly, L. K. (2013). Normal newborn as-sessment & care. In A. H. Decherney, L. Nathan, N. Laufer, & A. S. Roman (Eds.), Current diagnosis & treatment: Obstetrics & gynecology (11th ed., pp. 181–189). New York, NY: McGraw-Hill.

Sadowski, S. L. (2010). Cardiovascular disorders. In M. T. Verklan & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (4th ed., pp. 534–588). St. Louis, MO: Saunders.

Pearson Nursing Student Resources Find additional review materials at: pearsonglobaleditions.com/London

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Like most parents, when I held my son for the first time, I checked that all his fingers and toes were present. Then he looked at me with wide, bright, serious eyes and began my introduction to his unique personality. —Leah, 23

Learning OutcOmes

25.1 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

25.2 Summarize the components of a systematic physical assessment of the newborn.

25.3 Describe the normal physical characteristics and normal variations of the newborn and compare abnormal findings to possible causes and nursing responses.

25.4 Describe the components of a neurologic assessment and the neurologic/neuromuscular characteristics of the newborn and the reflexes that may be present at birth.

25.5 Compare the components of the newborn behavioral assessment with the normal behavioral characteristics and normal variations of the newborn.

25.6 Correlate findings in a newborn behavioral assessment to nursing responses and to teach and involve parents in the care of their newborn.

25CHAPTER

Nursing Assessment of the Newborn

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Newborns communicate their needs primarily by behavior. Because nurses are the most consistent professional observers of the newborn, they can translate this behavior into information about a newborn’s condition and

respond with appropriate nursing interventions. This chapter focuses on the assess-ment of the newborn and the interpretation of these findings.

Newborn assessment is a continuous process designed to evaluate development and adjustments to extrauterine life. In the birth setting, the Apgar scoring proce-dure and careful observation form the basis of assessment and are correlated with information such as the following:

■ Maternal prenatal history■ Birthing history■ Maternal analgesia and anesthesia■ Complications of labor or birth■ Treatment instituted immediately after birth, in conjunction with

determination of clinical gestational age■ Consideration of the classification of newborns by weight and gestational age

and by neonatal mortality risk■ Physical examination of the newborn

The nurse incorporates data from these sources with the assessment findings during the first 1 to 4 hours after birth to formulate a plan for nursing intervention.

The various newborn assessments and the data obtained from them are valu-able only to the degree to which they are shared with the parents. The parents must be included in the assessment process from the moment of their child’s birth. The Apgar score and its meaning should be explained immediately to the family (see Chapter 19 88 for a discussion of the Apgar score). As soon as possible, the parents should take part in the physical and behavioral assessments as well.

The nurse encourages the parents to identify the unique behavioral characteristics of their newborn and to learn nurturing activities. Attachment is promoted when par-ents have an opportunity to explore their newborn in private and identify individual physical and behavioral characteristics. The nurse’s supportive responses to parents’ questions and observations are essential throughout the assessment process. The new-born physical examination is the beginning of newborn health surveillance and health education for the newborn’s family that continues into the community setting.

timing Of newbOrn assessmentsDuring the first 24 hours of life, the newborn makes the critical transition from intrauterine to extrauterine life. The risk of mortality and morbidity is statistically high during this period. Assessment of the newborn is essential to ensure that the transition proceeds successfully.

There are major time frames for assessments of newborns while they are in the birth facility.

■ Delivery room disposition. The first assessment is done in the birthing area immediately after birth to determine the need for resuscitation or other interventions. The stable newborn should stay with the family after birth to initiate early attachment. The newborn with complications is usually taken to the special nursery for further evaluation and intervention.

■ Nursery or couplet care admission examination. A second assessment may be done by the nursery nurse as part of routine admission procedures. During this assessment, the nurse carries out a brief physical examination to estimate gestational age and evaluate the newborn’s adaptation to extrauterine life. No later than 2 hours after birth, the admitting nursery nurse should evaluate

K e y t e r m s

578

Acrocyanosis, 589

Barlow maneuver, 599

Brazelton Neonatal Behavioral Assessment Scale, 603

Caput succedaneum, 592

Cephalohematoma, 592

Chemical conjunctivitis, 593

Epstein pearls, 594

Erb-Duchenne paralysis (Erb’s palsy), 599

Erythema toxicum, 589

Forceps marks, 590

Gestational age assessment tools, 579

Harlequin sign, 589

Jaundice, 589

Lanugo, 580

Milia, 589

Molding, 591

Mongolian blue spots, 590

Moro reflex, 602

Mottling, 589

New Ballard Score (NBS), 579

Nevus flammeus (port-wine stain), 590

Nevus vasculosus (strawberry mark), 590

Ortolani maneuver, 599

Palmar grasping reflex, 601

Pseudomenstruation, 598

Rooting reflex, 602

Skin turgor, 589

Stepping reflex, 602

Subconjunctival hemorrhage, 593

Sucking reflex, 603

Telangiectatic nevi (stork bites), 590

Thrush, 594

Tonic neck reflex, 601

Vernix caseosa, 590


Es t imat ion o f Ges ta t iona l Age 579



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neurologic evaluation findings based on reflexes or assessments dependent on the higher brain centers may not be reliable. If the neurologic findings drastically deviate from the gestational age derived by evaluation of external characteristics, a second assess-ment is done in 24 hours.

The neurologic assessment components (excluding reflexes) can aid in assessing the gestational age of newborns of less than 34 weeks’ gestation. Between 26 and 34 weeks, neurologic changes are significant, whereas significant physical changes are less evident. Ballard, Khoury, Wedig, et al. (1991) developed the estimation of gestational age by maturity rating, a simplified ver-sion of the well-researched Dubowitz tool. The Ballard tool omits some of the neuromuscular tone assessments, which are diffi-cult to assess in very ill newborns or those on respirators, and leg recoil. In the Ballard tool, each physical and neuromuscular finding is given a value, and the total score is matched to a gesta-tional age. The maximum score on the Ballard tool is 50, which corresponds to a gestational age of 44 weeks.

For example, on completion of a gestational assessment of a 1-hour-old newborn, the nurse gives a score of 3 to all the physi-cal characteristics, for a total of 18, and gives a score of 3 to all neuromuscular assessments, for a total of 18. The physical char-acteristics score of 18 is added to the neurologic score of 18 for a total score of 36, which correlates with 38+ weeks’ gestation. Because all newborns vary slightly in the development of physi-cal characteristics and maturation of neurologic function, scores usually vary instead of all being 3.

Postnatal gestational age assessment tools can overestimate preterm newborns of less than 28 weeks’ gestational age and un-derestimate postterm or more than 43 weeks’ gestation. Ballard et al. (1991) in the New Ballard Score (NBS) added criteria for more accurate assessment of the gestational age of newborns between 20 and 28 weeks’ gestation and less than 1500 g. They suggest that the assessments should be made within 12 hours of birth to optimize accuracy, especially in infants of less than 26 weeks’ gestational age. Also the Ballard assessment may be overstimulating to infants of less than 27 weeks’ gestation ( Gardner & Hernandez, 2011). Some maternal conditions, such as preeclampsia, diabetes, and maternal analgesia and anesthesia, may affect certain gestational assessment components and war-rant further evaluation. Maternal diabetes, although it appears to accelerate fetal physical growth, seems to retard maturation. Maternal hypertension states, which retard fetal physical growth, seem to speed maturation.

Newborns of women with preeclampsia on magnesium sulfate may have a poor correlation with the neuromuscular criteria involving active muscle tone and edema. Maternal an-algesia and anesthesia may cause respiratory depression in the baby. Babies with respiratory distress syndrome (RDS) tend to be flaccid and edematous and to assume a “froglike” posture (see Chapter 29 88 for a discussion of RDS). These characteris-tics affect the scoring of the neuromuscular components of the assessment tool used. The NBS gestational age assessment tool will be used throughout the chapter to demonstrate the assess-ment of the physical and neuromuscular criteria associated with gestational age.

the newborn’s status and any problems that place the newborn at risk (Gleason & Devaskar, 2012).

■ Before discharge examination. A certified nurse-midwife (CNM), physician, or nurse practitioner will carry out an exam similar to the well-baby admission exam. This includes a behavioral assessment and additional informa-tion from the baby’s stay in the birthing unit to assess if the infant is ready for routine care at home. A complete physi-cal examination is done to detect any emerging or potential problems. When the birthing center stay is short, a combi-nation admission-discharge exam is appropriate.

This chapter presents the procedures for estimating gestational age and performing the complete physical examination and behavioral assessment. Chapter 19 88 discusses the immediate postbirth assessment. Chapter 26 88 describes the brief assess-ment performed during the first 4 hours of life.

estimatiOn Of gestatiOnaL ageThe nurse must establish the newborn’s gestational age in the first 4 hours after birth so that careful attention can be given to age-related problems. Traditionally, a newborn’s gestational age was determined from the date of the pregnant woman’s last men-strual period. However, this method was accurate only 75% to 85% of the time. Because of the problems that develop with the preterm newborn or the newborn whose weight is inappropri-ate for gestational age, a more accurate system was developed to postnatally evaluate the newborn. Once learned, the procedure can be done in a few minutes.

Safety alert!It is essential that the nurse wear gloves when assessing the newborn in these early hours after birth and before the first bath until amniotic fluid, as well as vaginal and bloody secretions on the skin, are removed.

Clinical gestational age assessment tools have two com-ponents: (1) external physical characteristics and (2) neurologic or neuromuscular development. Physical characteristics gener-ally include the following:

■ Sole creases■ Amount of breast tissue■ Amount of lanugo■ Cartilaginous development of the ear■ Testicular descent and scrotal rugae in the male■ Labial development in the female

These objective clinical criteria are not influenced by labor and birth and do not change significantly within the first 12 hours after birth.

The neurologic examination facilitates assessment of func-tional or physiologic maturation in addition to physical devel-opment. A variety of factors can affect the newborn’s nervous system, which is unstable during the first 24 hours of life;


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