I. Newborn Assessment 22/6/2010 - جامعة آل البيت · PDF file–Postnatal...

11/07/1432 Miss: kamlah Olaimat

I. Newborn Assessment

22/6/2010

http://www.solarnavigator.net/animal_kingdom/humans/humans.htm

11/07/1432 Miss: kamlah Olaimat 2

Terminology

Newborn refers to a recently born infant in the

first few hours of life

Neonate refers to infants in the first 28 days of

life

Examination precaution

Hand washing

Thermal environment

Light and noise

5-10 minutes examination time


Timing and Types of Newborn

Assessments• Immediately after birth

- Need resuscitation?

- Can be placed with mother?

• Within 1 to 4 hours after birth.

- Adaptation to extra uterine life and progress?

- Determine GA?

-Important history point in caring of newborn?

• Assessment procedures within first 24 hours or before discharge

- Complete physical examination

- Nutritional status and ability to formula-feed or breastfeed


Important History points in caring

of newborn

• Maternal diabetes: Metabolic and congenital defect

• Polyhydramnios: Swallowing defect, GI obstruction

• Oligohydramnios: Renal disease, pulmonary hypoplasia

• Maternal age: Old age and chromosoma

• Rupture of membrane: sepsis

• Delivery type: c/s and TTN

• Maternal blood group: ABO, Rh disease

• Infection risk: Maternal Hepatitis carrier


Initial Assessment

• Modified position which aids drainage of mucus from

nasopharynx and trachea by gravity

• The newborn assessment is performed immediately

after birth.

• Respiratory effort, heart rate and skin color for

perfusion are evaluated using the APGAR scoring

system at 1 and 5 minutes after birth.

• Listen for breath sounds in the mid-axillary area.

• Palpate the pulse at the umbilical stump or apically on

the chest.


Apgar Score• Score of 0 – 2 for each item, then totaled.

• Apgar Score 8 or higher no intervention

• Apgar Score 4 – 8 gentle rubbing, oxygen

• Apgar Score 0 – 4 resuscitation

Points Given 0 1 2

A Activity/muscle

tone

Limp/flaccid Some

motion/flexion

Active motion/well

flexed

P Pulse Rate Absent <100 bts/min >100 bts/min

G Grimace/Reflex

Irritability

No Response Grimace Cry, cough, sneeze

A Appearance/

Skin Color

Blue, Pale Body pink,

extremities blue

Pink all over

Absence of cyanosis

R Respiration Absent Slow weak cry Good Cry


Assessment of Gestational Age

• An accurate assessment incorporates size

and maturity.

• Assessment methods include:

– Mother’s menstrual history

– Prenatal ultrasonography

– Evaluation of obstetric parameters

– Postnatal maturational examinations

• Dubowitz Assessment of Gestational Age

• New Ballard Score


Postnatal assessment of gestational age

• EDD is not always correct (only accurate 75-85% of the time)

• Performing a gestational exam helps the nurse evaluate for

potential age-related problems. Should be done in the first 4 hours

of life.

• Accuracy within 1-2 weeks

• New Ballard Score (NBS)

– physical maturity

– neuromuscular maturity

Ballard Score tool: each physical and neuromuscular finding is

given a value, and the total score is matched to a gestational age

The maximum score on the Ballard tool is 50, which corresponds to a

gestational age of 44 weeks


Assessment of Physical Maturity

Characteristics

• Resting posture

Flexion of the thigh & extension of the upper

extremities ( score1or 2)-GA 31wk

Stronger flexion of the arm, hips and thigh (

score 3-GA 35 wk

Hypertonic flexion of all extremities ( score 4



Characteristics-Cont.

• Plantar Surface-Sole creases

Few sole creases on the anterior portion of the

foot (score 2-GA 35 wk)

Deeper sole creases on the anterior 2/3 of the

sole ( score 3-GA 37 wk)

Deep sole creases down to include the heel (

score 4).




• Breast tissueGently compress the tissue between the middle and

index fingers and measure the tissue in cm or mm

Visible raised area of ,75 cm diameter ( score 3- GA

38 wk)

10mm breast tissue area ( score 4- GA 40-44 wk

Absence of or decreased breast tissue indicate

premature or SGA.




• Ear form & cartilage

Incurving of the upper 2/3 of the pinna ( score 2- GA 36 wk)

Well-defined incurving of the entire pinna ( score 3)

If the auricle stays in the position in which it is pressed or returns slowly to its original position-≤ 38 wk


Estimation of Gestational Age ()

PHYSICAL CHARACTERISTICS:• Resting posture: assessed undisturbed on a flat surface• Skin: thin, opaque, peeling• Lanugo: decreases as gestational age increases• Sole (plantar) creases: increase with gestational age• Areola and breast bud tissue: increases with age.• Ear form and cartilage distribution: Cartilage gives shape.

Pinna is firm at term.• Male genitals: Size of scrotal sac, the presence of rugae, and

descent of the testicles.• Female genitals: size of labia majora and minora.• Vernix: None in the post term infant. More seen with

prematurity.• Hair: Preterm patchy, term silky.• Skull firmness: increases as the fetus matures.• Nails: long may be a sign of postmaturity.


NEW BALLARD SCORE

SCORE WEEKS

-10 20

-5 22

0 24

5 26

10 28

15 30

20 32

28 34

30 36

38 38

40 40

48 42

50 44

PRETERM

TERM

POSTTERM


NEUROMUSCULAR MATURITY

• Square window-bend wrist so palm is as flat against the arm as possible

– 90 degrees (32 wks or less) –score of 0

– If angle greater than 90 degrees-score is 1

• Arm recoil-arms held with elbows flexed then pulled straight down to sides and released.

– Rapid recoil-score of 4

– Preterm0no recoil-score of 0

• Popliteal angle-thigh flexed to abdomen, hips remain flat on table, lower leg is straightened until resistance met

– If can be fully extended-score is 1

– If angle is less than 90 degrees (measured angle behind knee) score of 5


NEUROMUSCULAR MATURITY

• Scarf sign-arm drawn across body toward other shoulder until resistance is met (measurement of elbow placement to midline)

– If elbow did not reach midline-score of 4

– If elbow goes past midline-score of -1

• Heel to ear-hips on table, foot is moved toward the ear on same side until resistance met

– Foot position relative to knee extension is noted

– Pre-term infant’s leg will remain straight & the foot will be near the ear

– Closer to term more resistance will be felt and more flexion will be noted


Square window Popliteal angle

Scarf sign Heel to ear-hips

11/07/1432 Miss: kamlah OlaimatArm recoil

Posture


ESTIMATION OF GESTATIONAL

AGENBS - continued SCORING SYSTEM

-10 20 wks 25 34 wks

-5 22 wks 30 36 wks

0 24 wks 35 38 wks

5 26 wks 40 40 wks

10 28 wks 45 42 wks

15 30 wks 50 44 wks

20 32 wks


Case Study

• A nurse has completed the gestational assessment on a

newborn who weighs 3000 g, is 48 cm long, with a head

circumference of 33 cm. His APGAR scores were 8 at one

minute and 9 at five minutes. Other assessment data

include skin dry and cracking, no lanugo, sole creases

covering the whole heel, areola 3 mm, pinna soft with slow

recoil, testes descended with moderate rugae. Reflex data

include square window at 0°; arm recoil 100°; popliteal

angle 100°; scarf sign yield elbow at midline; heel to ear

90°; and posture fully flexed. The parents express concerns

over his small size.


Gestational Age Relationship to Intrauterine Growth

• Growth curves show measures of intrauterine growth in

percentiles for each week of gestation.

• Birth weight is classified as follows:

• Large for gestational age (LGA): weight falls above the

90th percentile for gestational age

• Appropriate for gestational age (AGA): weight falls

between the 90th and 10th percentile for gestational age

• Small for gestational age (SGA): weight falls below the

10th percentile for gestational age


Blink reflex:

Used to protect the eye, newborn close his lids when any near object come close to his eye. Elicited by flashing strong light in the newborn’s eye.

Rooting reflex:

Used to help newborn find the food. When brushing the cheek near to the corner of the mouth, the newborn will turn to that direction, it disappear at 6 weeks of life.


Swallowing, gag, cough and sneeze reflex: Swallowing occur automatically when food reaches

the posterior portion of the tongue.

Extrusion reflex: Used to protect the newborn from swallowing objects. he extrude any object that is placed in the anterior portion of the tongue. It disappears in the forth month.

Sucking reflex:

Newborn suck when his lips is touch, disappear in 6 months. If never stimulated, it disappears (such as newborn with trachoesophegial shunt, in which food is not allowed to be given by mouth), so newborn is given pacifier to keep this reflex.


palmer grasp:

Newborn grasp objects placed in their palm by closing their fingers on it. Disappears by the third month.

Step in place (dancing) or walk in place:

Newborn who are held in vertical position with their feet touching a hard surface, will take a few quick alternating steps. Disappear by the third month.


Planter grasp:

When touching the sole of the newborn’s feet at the base of the toe, the toes grasp. Disappears in about 8-9 months.

Tonic neck reflex:

When you turn the newborn’s head to one side, the leg and the arm of the same side will extend and the opposite side will flex. Disappears at 2-3 months.


Moro reflex (startle):

By startling the newborn with loud voice, the newborn will abduct and extend their arms and legs. And their fingers assume a typical “C” position. Then they adduct their legs and arms. Disappears at 4-5 months.

Babaniski reflex:

When stroking the foot with inverted “J”, from heel to upward. Newborn will fan his fingers and extend them outward. Disappears at 12-18 month.


Crossed extension:

If one leg is irritated at sole while supine and legs are extended, the newborn will raise the other leg and cross it to the first leg.

Trunk incurvation:

When newborn is on prone position, and touched on one side, he will flex and swing their pelvis toward the touch.


1- Hearing:

Fetus hear in uterus before birth, and as they born they hear from near distance. As evidence: they calm in respond to soothing voice and startle at loud voice.

2- Vision:

Newborn see when they born, but they focus on white & black objects at distance of 9-12 inches.

3- Taste:

Newborn prefer sweet taste of milk or glucose water.

4- Smell:

They can smell after clearness of nose from mucus & amniotic fluid.


Time Description

First period 15-30 min Reactive period

Looks cyanosis.

Rapid pulse.

Rapid respiration.

alert.

Second period 30-120 min Resting period

Newborn is sleeping.

V/S stabilized.

Color stabilized.

Third period 2-6 hrs Second reactive period

Alert.

Color & V/S signs change with activity.


1- baby is no longer under the influence of the maternal hormones.

2- diuresis occur (increase in second to third day of life).

3- newborn pass stool.

4- Limited intake (especially B.F baby). In which milk is low caloric.

Newborn lose 5%-10% of weight during the first 10 days of life, because:

Weight

After loss:

In first day WT is stable. The next 7 days is needed to regain WT for formula feed babies. and 10 days is needed to regain WT for breastfeed babies.

11/07/1432 Miss: kamlah OlaimatWeight 2.5 to 4 kg 34

Length The average length after birth for girls: 53 cm. The average length after birth for boys: 54 cm.

Head Circumference:

From 34-35 cm at birth, not < 33 or > 37.

Chest Circumference

From 32-33 cm at birth. It is less than the head with two cm until age of two years.


Vital Signs• Temperature- first is usually taken axillary,

but may be taken rectally to assure anal patency (36.5-37.5 c° )

– Crying may elevate temperature

– Stabilizes in 8 to 10 hours after delivery

• Axillary vs Rectal about 0.2 to 0.5 difference

• Pulse- 120-160 bpm, unless sleeping (100) or crying (180)

– Apical pulse for one minute

– Color pink with acrocyanosis

– Heart rate may be irregular with crying

• Respirations- 30-60 with periodic breathing

• B/P- only if suspected heart problem or premature infant

– Ranges between 60-80 mm systolic and 40-45 mm diastolic.


Newborn lose heat by four mechanisms:

1- convection: heat flow from newborn to cooler air. 2- radiation: transfer heat from body to cold solid object not in contact with the body. 3- evaporation: conversion of liquid to vapor. 4- conduction: transfer heat from body to cold solid object in contact with the body.

Insulation is not efficient because little fat available.** How newborn conserve heat?From the brown fat that available in the

intrascapular, thorax and perineal area. It found in the mature newborn and produce heat by increasing metabolism.

Temperature


Conduction

Evaporation

Convection

Radiation


Temperature Assessment

• For neonates and infants, axillary temperatures closely correlate with rectal temperatures and are safer for the infant.

• Axillary temperature, on average, is 0.4 C less than rectal temperature (Kenner, 2003).

• At birth, the neonate’s temperature may decrease at a rate of 0.2 C to 1.0 C per minute, mainly through convective and evaporative heat loss.

• Norms (AAP & ACOG, 2007):

– Rectal or auxiliary temperature of 36.5 C to 37.5 C

– Skin temperature of 36 C to 36.5 C


Heat ProductionThe human body responds to cold in three

ways:

1. Voluntary muscular activity (vasoconstriction and increased movement)

2. Shivering (inefficient in the term newborn)

3. Chemical or nonshivering thermogenesis (brown-fat metabolism for several hours after birth)


Heat Dissipation• Infants respond to overheating by

vasodilation in the skin, which increases heat loss from the blood.

• In the first week of life, immaturity of the skin causes the largest amount of heat loss through evaporation.

• The newborn’s head represents 21 percent of the total body surface area and accounts for a significant proportion of total heat loss (Blackburn, 2007).


Weight and Measurements

• Weight: 2500-4000gms

Wt loss 5%-10% for term newborn, 15% for preterm

Growth 198-200g / wk for the 1st 6 months

• Length: 50cm ( 46-56cm, 2.5 cm/month for 1st 6 months

• Head circumference: 32-37 cm, 2cm larger than chest ((measure right above eyebrows)

• Chest circumference: 32cm (30-35 cm) (measure at nipple line)


Physical Examination

• skin

– Pink is normal

– Acro cyanosis is normal

– Cyanosis

– Jaunduce

• 1st 24 hours

– Pale and grayish color in anemia and acidosis

respectively

– Common skin rash

• Erythema toxicum, mongolian spot,


Clinical assessment

Skin: some common normal findings• Vernix caseosa: a cream/white cheesy material on the skin at

birth which cleans off easily with oil.

• Lanugo; fine downy hairs seen on the back and shoulders especially in preterm infants.

• Milia: pinpoint whitish papules on nose and cheeks due to blocked sebaceous glands.

• Mongolian blue spots: grey/bluish pigment patches seen in the lumbar area, buttocks and extremities in dark skinned babies.They usually disappear by one year.

• Capillary heamangiomas (“stork bite” naevi): red flat patches which blanch with gentle pressure. Commonly occur on upper eyelids, forehead and nape of the neck.

• Erythema toxicum: small white/yellow papules or pustules on a red base seen on face, trunk and limbs. Develop 1 – 3 days after birth and usually disappear by one week.


Erythema toxicum, acrocyanosis, milia and

mongolian spots


Clinical assessment

HeadAfter these general observations, examine the infant

starting with the head and moving down the body.

• Observe the size and shape of the head (micro- or macrocephaly; cephalhaematoma)

• Check the anterior and posterior fontanelles and that the skull sutures feel normal

• Form and position of ears (low set ears occur in chromosomal abnormalities, e.g. Down syndrome)

• Molding is shaping of fetal head to adapt to the mothers pelvis during labor (suture lines overlap and head elongates)


Anterior Fontanel:

At the junction of two parietal & frontal bones.

Diamond in shape, 2-3 cm in width & 3-4 cm in length.

Close at 12-18 months.

Posterior fontanel:

At the junction of two parietal & the occipital bones.

Triangular shape, 1 cm in length.

Close at 2-3 months.


COMPARISON OF

CEPHALHEMATOMA AND CAPUT

SUCCEDANEUM

• CEPHALHEMATOMA –is a collection of blood resulting

from ruptures blood vessels between the surface of a cranial

bone and the periosteal membrane. They may be bilateral or

unilateral and do not cross the suture lines

• CAPUT SUCCEDANEUM

is a localized, easily identifiable, soft area of the scalp,

generally resulting from a long and difficult labor or vacuum

extraction.


Moulding

Caput

Cephalohematoma


• Facial Symmetry

• Eyes- shape, slanted,

hemorrhages,

edema, strabismus

Asymmetry

Slanted eyeshemorrhages

Strabismus

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•Nose- patency of

each nares to r/o

“Choanal Atresia”


• Mouth- for cleft lip and palate, for

neonatal teeth, Thrush

Cleft lipCleft palate Thrush

Neonatal teeth

http://www.plastic-surgery.gr/images/cleftlp1.jpg

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•Ears-

•normal shape

•patent

•even with eyes (low set ears indicate

congenital abnormalities)

•Pits or tags


• Neck and Clavicles- is the neck thick or webbed, do the clavicles feel intact, no crepitus.

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Clinical assessment

Cardiovascular and respiratory• Feel femoral and radial pulses for volume, rate and rhythm.

• In aortic coarctation, femoral pulse is reduced, absent or not synchronous with radial pulse.

• If child is sick, measure blood pressure.

• Locate the apex beat and listen to the heart sounds for murmurs.

• Count the respiratory rate

– normal 30 – 40 breaths/min in term infants

– faster in preterms.

– > 60 / minute abnormal

• Observe for respiratory distress: nasal flaring, intercostal and subcostal recession.


Chest

- Size- 2” smaller than head

- Shape- cylinder shape is normal. Asymmetry can be caused by Pneumothorax or Diaphragmatic Hernia

- Nipples- location, distance apart, any accessory nipples


Lung Sounds

- clear or moist, equal, sounds in

chest?

- S/S of respiratory distress

- (tachypnea, grunting, retractions,

nasal flaring, cyanosis)

- Rate (listen for 1 full minute)


Factors that initiate Respirations

• 1) Chemical Factors- in O2 and in CO2

causes impulses to stimulate the respiratory

center in the medulla of the brain.

• 2) Thermal Factors- abrupt temperature

change sends impulses to brain

• 3) Mechanical Factors- fetal chest is

compressed during birth, forcing fluid out.

• 4) Factors that maintain respirations-

surfactant, functional residual capacity


Heart Sounds• - Auscultate for rate & rhythm

• - presence of murmurs (murmurs are common in the newborn period- 90% are transient and considered normal)

• Listen for 1 full minute

• Report any abnormal rate, rhythms or sounds to pediatrician

• If suspected heart problem- take B/P on all four extremities


Cardiovascular Adaptation: Transition from

fetal to neonatal circulation

• What is fetal circulation?

• A combination of structures/vessels that are present only during the fetal period, which help shunt the highest oxygenated blood to the head, brain and heart.

• 1) Ductus Arteriosus

• 2) Foramen Ovale

• 3) Ductus Venosus


At birth, after the first few breaths, the

following cardiovascular changes occur:

• 1) Ductus Arteriosus closes in response to O2 and resistance in lungs

• 2) Pulmonary blood vessels dilate in response to demand in lungs

• 3) Foramen Ovale is forced to close because of increased pressure in left side of heart

• 4) Ductus Venosis constricts when umbilical cord is clamped


Abdomen• Inspection

Size- smaller than chest, Shape- rounded, no distention

– Scaphoid

– Distention

– Abdominal wall defect (gastroschisis, Omphalocele)

• Palpation; baby sucking and use warm hands

– Kidneys are normaly palpable

– Liver 2-3 cm

– Spleen palpable

– Bowel sounds- present, hypo, hyper

- Cord- color, # of vessels, clamp on tight (no skin attached), no

bleeding noted

– Hernias ; umbilical and inguinal


Intestines is sterile in newborn, it cultured by normal flora in 5-24 hours. ** Stool: First stool: is called meoconium, it is black to green in color, odorless, sticky. 2nd -3rd day: called transitional stool, green in color, loose (like diarrhea).

4th day:

In breastfeed babies: In formula feed babies:

Light yellow with sweat smelling (high in lactic acid). 3-4 times/ day.

Bright yellow, with odor. 2-3 times/day.


Clinical assessment

Spine and genitaliaExamine:

• The spine for dimples, tuft of hair (spina bifida occulta) or cystic swellings (spina bifida cystica)

• Remove the diaper to examine the genitalia. In boys, confirm that both testicles have descended into the scrotum.

• Designate the infant’s sex

• Inspect the perineum and check anus for position and patency (can be done by gently checking rectal temperature)


Genitalia:

- Female- labia may be swollen and red from delivery, hymenal tag, pseudomenses, whitish drainage

- Male- testes should be descended at term, rugae on scrotum, check where urinary meatus comes out

- Hypospadias- urethral opening is on the underside

- Epispadias- urethral opening is on the upperside

-


The average first void id within the first 24 hours of life. It is light-colored and odorless. The first void is about 15 ml. The daily urine out put: in first 1-2 days: 30-60ml. By the end of the first week: the total output is about 300ml.

When child perform the following activities, his nervous system consider normal:

Moving extremities. Attempting to control movement. Cry strongly.Demonstrate reflexes


Extremities

• Arms & Hands

• Symmetry

• 10 fingers

• Brachial pulse

• Erb’s palsy: extended arm and internal rotation with limited movement

• Humerous fracture

• Single palmar crease

• Hip dislocation– Female, breach


Polydactly

Syndactyly

Simian Crease

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Any problems identified during the initial assessment will need specific management. However, newborn infants are a highly susceptible group and high-quality routine care prevents a multitude of problems. The major elements of routine care include:

• Cord care

• Thermal control

• 24 hour rooming in

• Feeding

• Immunization

• Maternal education on hygiene and every other aspect of routine care

Routine care of the well newborn

Hand washing with soap and water every time a baby is

handled goes a long way in reducing the risk of infection!


• 5) Bathing-

• *remember Thermoregulation

• Good time to observe for any missed abnormalities

• Sponge bath until cord falls off

• 6) Cord care-

• Alcohol, Betadine,

• Teach parents how to care for cord and when to expect it to fall off


• 7) Protection of Infant-Security, ID badges, observation of any suspicious looking people

• 8) Teaching Parents

• NB Care

• Feeding

• When to call the Doctor

• Lab tests

• Hearing Screen


Nursing Care Management of the

Newborn

Nursing Diagnosis

• Risk for ineffective breathing pattern

• Altered nutrition: less than body requirements

• Altered urinary elimination

• Risk for infection

• Knowledge deficit

• Altered family processes


Nursing Plan and Implementation

• Maintenance of cardiopulmonary function

• Maintenance of a neutral thermal environment

• Promotion of adequate hydration and nutrition

• Promotion of skin integrity

• Prevention of complications and preventing safety

• Enhancing parent-newborn attachment


Maintenance of Cardiopulmonary

Function

• Assess vital signs every 6 to 8 hrs or more depending on the newborn’s status.

• “Back to Sleep” , side lying to prevent aspiration and facilitate drainage of mucus.

• Keep bulb syringe readily available.

• Vigorous fingertip stroking of the spine frequently stimulates respiratory activity.

• Cardiac/respiratory monitor may be required.

• At-risk indicators: pallor, cyanosis, ruddy color, and apnea.


Promotion of Adequate Hydration and

Nutrition

• Weigh at the same time each day.

• Weight loss of up to 10% is considered normal during the first week of life.

• Birth weight should be regained by the 2nd week of life.

• The nurse records voiding and stooling patterns.

• The first void should occur within the first 24 hours and passage of stool in the first 48 hours.

• Assess for abdominal distention, bowel sounds, hydration, fluid intake, voiding pattern, and temperature stability.

• Excessive handling may cause an increase in the newborn’s metabolic rate, calorie use and fatigue.


Promotion of Skin Integrity

• Bathing is important for health, appearance, and infection control in the nursery.

• Ongoing skin care includes cleansing of the buttocks and perineal area with water and a mild soap with diaper changes.

• Assess the umbilical cord for signs of bleeding or infection: 1) apply triple dye on admission to nursery and 2) alcohol after each diaper change.

• Cord care with each diaper change.

• Eye and skin care related to phototherapy.

• Skin care following circumcision.


Prevention of Complications and

Promoting Safety

• Pallor may be an early sign of hemorrhage.• Circumcision is assessed for signs of hemorrhage and

infection.• Initial scrub for 2-3 minutes when direct contact with the

newborn is anticipated.• Handwashing between each client contact and contact with

floor, face, or any soiled surface.• Encourage parents to wash hands prior to holding the infant

and wear a gown over street clothes.• Teach parents to limit visitors who may have a communicable

disease.• Check namebands with each encounter with the parents.• Instruct clients in security measures in place to prevent infant

abduction.


Enhancing Parent-Newborn

Attachment

• Involve the entire family in newborn care

• Infant massage may be encouraged

• Increase skin to skin contact

• Read to or play music for the newborn

• Encourage cuddling and talking to the infant


Discharge Planning and Preparation

• Parent teaching

• General instructions for newborn care

• Nasal and oral suctioning

• Wrapping the newborn

• Sleep and activity

• Safety considerations

• Newborn screening and immunization Program


Please take good care of me!

Ref:

1. Ladewig, P., London,M., &

Davidson,M. ( 2010)

Contemporary Maternal-

Newborn Nursing Care, 7th

ed.,Pearson Education Ltd.,

London.

2. Classes.kumc.edu/son/nurs350/a

ssessment_findings_for_bj.htm

I. Newborn Assessment 22/6/2010 - جامعة آل البيت · PDF file–Postnatal...

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Transcript of I. Newborn Assessment 22/6/2010 - جامعة آل البيت · PDF file–Postnatal...