Essentials of Maternity, Newborn, and Women's Health Nursing


CHAPTER 17: Newborn Transitioning

Sarah works in the labor and delivery unit as a transition nurse. Her department has instituted a new bedside transition period where newborns make the transition to extra uterine life in their mother’s recovery room about an hour after birth. Sarah’s next assignment is a new baby boy with Apgar scores of 8 and 9, born by cesarean about 1 hour ago to Lindsay, a 28-year-old G1. Sarah’s assessment findings of the new baby boy are:

· Vital signs: axillary temperature 37.0° C, heart rate 145, respiratory rate 75

· Observations: color pink, respirations rapid and unlabored, good muscle tone, good arm and leg movement

· Auscultation: breath sounds clear and equal bilaterally, strong heart sounds with a soft murmur, active bowel sounds in all four quadrants

· Physical assessment: fontanels soft and flat, eyes clear with red reflex in both, ears normal shape and placement, soft and hard palate intact, strong suck, both nares patent, capillary refill less than 2 seconds, both testes descended

· Measurements: weight 8 pounds 6 ounces, length 20 inches, head circumference 36.2 cm, chest circumference 36.0 cm

1. Which assessment findings for this newborn are abnormal? What is the most likely cause of these abnormal findings?

The assessment shows that the baby has a high respiratory rate of seventy five. The normal respiratory rate for infants range from 30 to 60. When it goes higher than that then the baby is having some respiratory problems. This abnormality might be caused by respiratory distress syndrome or transient tachypnea of the new born.  It is TTN… RDS is a diagnosis of prematurity.  Go read about TTN.

0. How would Sarah explain these abnormal findings to Lindsay?

Respiratory distress happens when the baby has difficulties in breathing. The difficulties may occur due to abnormalities in the lungs, nose, heart, and other respiratory passages. Sometimes, infants experience labored and high respiratory rates because their respiratory system is well and fully developed (Rici, 2013)..  this is a generic answer… 

0. Describe the nursing interventions that Sarah would implement based on these findings.

In this case, the most effective nursing interventions for the baby would be administering intratracheal surfactant and prophylactic surfactant.  This is done for prematurity...not the problem and it is a medical intervention NOT nursing..

The two are rescue interventions to enable the baby breath and supply the body with enough oxygen. 

Baby girl Destiny was born by cesarean delivery 2 days ago. Destiny weighed 7 pounds 3 ounces, length 19 inches, head circumference 34 cm, and chest circumference 34 cm. Her newborn course has been unremarkable. You observe that when held, Destiny appears alert and stares into her caregiver's face. Destiny appears to be a content baby and cries only when she is hungry or when she needs a diaper change. When hungry, you observe that she brings her hand to her mouth and starts sucking on her fist and then begins to cry. Destiny falls asleep immediately after the feeding. The telephone, which is next to Destiny on her mother’s bed, rings loudly and Destiny does not appear to respond to the loud sound by moving her extremities or awakening briefly. (Learning Objective 5)

i. Based on your observations of Destiny, are her behaviors normal? Which of the five typical behavioral responses were observed?

Destiny’s behaviors are not normal. Out of the five typical behavioral responses, crying is clearly observed with baby Destiny. She cries when she is hungry and when she needs a diaper change. Mostly infants communicate through crying. Also, reflex response is observed especially sucking. When she is hungry, she brings her fist to the mouth and begins to suck it. 

ii. Does Destiny exhibit any behaviors that may be cause for concern? What is the concern and what might you as the nurse do to assess further?

The main behavior exhibited by the baby that causes concern is hearing. Infants have the ability to hear and react to sounds and voices. Therefore, the major concern could be ability of the child to hear. As a nurse, I would use otoacoustic emissions method to assess the hearing of the baby. 


Ricci, S. S. Esentials of Maternity, Newborn, and Wom     ens health Nursing.(2013).