THE FIRST HOUR OF LIFE
The primary focus at this time is the transition from intrauterine to extrauterine life, with an introduction to family members as the neonate’s condition warrants.
NEONATAL ASSESSMENT DATA BASE (Full-Term)
Circulation
Apical pulse may fluctuate from 110–180 beats per minute (bpm).
Blood pressure 60–80 mm Hg (systolic), 40–45 mm Hg (diastolic).
Heart Sounds: Located in mediastinum with point of maximal intensity just to the left of the midsternum at third or fourth intercostal space.
Murmurs common during the first few hours of life.
Umbilical cord white and gelatinous; contains two arteries and one vein.
Elimination
May void at birth
May have passed meconium at birth
Food/Fluid
Weight: 2500–4000 g (5 lb 8 oz–8 lb 13 oz)
Length: 44–55 cm (18–22 in)
Skin turgor elastic (varies according to gestational age)
Neurosensory
Muscle Tone: Hypertonic flexion of all extremities.
Awake and active, demonstrates sucking reflex for first 30 min following birth (first period of reactivity).
Asymmetrical appearance (molding, edema, hematoma).
Cry strong, lusty, medium pitch (high-pitched cry suggests genetic abnormality, hypoglycemia, or prolonged narcotic effect).
Respiration
Apgar Score: 1/5 optimal score 7–10
Rate ranges from 30–60/min; periodic pattern may be noted
Breath sounds bilateral; occasional crackles common initially
Thorax cylindrical; prominent xiphoid cartilage common
Safety
Temperature ranges from 97.7°F–99.4°F (36.5°C–37.5°C).
Some vernix present (amount and distribution dependent on gestational age).
Skin: Smooth, flexible; peeling of hands/feet may be noted; pink-tinged or ruddy color; may be mottled, display minor bruising (e.g., forceps delivery), or harlequin color changes; petechiae on head/face (may reflect increased pressure associated with delivery or nuchal cord); port-wine stains, telangiectatic nevi (eyelids, between brows, or on occiput), or mongolian spots (primarily lower back and buttocks) may be noted.
Scalp abrasion may be present (internal electrode placement).
DIAGNOSTIC STUDIES
Cord pH: Levels of 7.20–7.24 reflect a preacidotic state; lower levels indicate significant asphyxia.
Hb/Hct: Hb level of 15–20 g and Hct of 43%–61%.
Direct Coombs’ Test on Cord Blood: Determines presence of antigen-antibody complexes on red blood cell (RBC) membrane, reflecting hemolytic condition.
NURSING PRIORITIES
1. Promote effective cardiopulmonary effort.
2. Provide a thermoneutral environment, and maintain body temperature.
3. Prevent injury or complications.
4. Promote parent-infant attachment.
Full Nursing Care Plan First Hour of Life
The primary focus at this time is the transition from intrauterine to extrauterine life, with an introduction to family members as the neonate’s condition warrants.
NEONATAL ASSESSMENT DATA BASE (Full-Term)
Circulation
Apical pulse may fluctuate from 110–180 beats per minute (bpm).
Blood pressure 60–80 mm Hg (systolic), 40–45 mm Hg (diastolic).
Heart Sounds: Located in mediastinum with point of maximal intensity just to the left of the midsternum at third or fourth intercostal space.
Murmurs common during the first few hours of life.
Umbilical cord white and gelatinous; contains two arteries and one vein.
Elimination
May void at birth
May have passed meconium at birth
Food/Fluid
Weight: 2500–4000 g (5 lb 8 oz–8 lb 13 oz)
Length: 44–55 cm (18–22 in)
Skin turgor elastic (varies according to gestational age)
Neurosensory
Muscle Tone: Hypertonic flexion of all extremities.
Awake and active, demonstrates sucking reflex for first 30 min following birth (first period of reactivity).
Asymmetrical appearance (molding, edema, hematoma).
Cry strong, lusty, medium pitch (high-pitched cry suggests genetic abnormality, hypoglycemia, or prolonged narcotic effect).
Respiration
Apgar Score: 1/5 optimal score 7–10
Rate ranges from 30–60/min; periodic pattern may be noted
Breath sounds bilateral; occasional crackles common initially
Thorax cylindrical; prominent xiphoid cartilage common
Safety
Temperature ranges from 97.7°F–99.4°F (36.5°C–37.5°C).
Some vernix present (amount and distribution dependent on gestational age).
Skin: Smooth, flexible; peeling of hands/feet may be noted; pink-tinged or ruddy color; may be mottled, display minor bruising (e.g., forceps delivery), or harlequin color changes; petechiae on head/face (may reflect increased pressure associated with delivery or nuchal cord); port-wine stains, telangiectatic nevi (eyelids, between brows, or on occiput), or mongolian spots (primarily lower back and buttocks) may be noted.
Scalp abrasion may be present (internal electrode placement).
DIAGNOSTIC STUDIES
Cord pH: Levels of 7.20–7.24 reflect a preacidotic state; lower levels indicate significant asphyxia.
Hb/Hct: Hb level of 15–20 g and Hct of 43%–61%.
Direct Coombs’ Test on Cord Blood: Determines presence of antigen-antibody complexes on red blood cell (RBC) membrane, reflecting hemolytic condition.
NURSING PRIORITIES
1. Promote effective cardiopulmonary effort.
2. Provide a thermoneutral environment, and maintain body temperature.
3. Prevent injury or complications.
4. Promote parent-infant attachment.
Full Nursing Care Plan First Hour of Life
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