Newborns: Nursing Diagnosis, Care Plans, And More

Infant delivery is commonplace in the U.S., with more than 3.6 million births annually. Most pregnancies and births happen without adverse events. However, the risk is always there, so nurses must be prepared to intervene quickly. 

Healthcare providers and nurses are the first professionals that come in contact with neonates and are responsible for ensuring safe delivery and assessing for any life-threatening abnormalities. While newborns have exceptional abilities to adapt to their new environment, it does not rule out the risks of potential problems in the first hours and days of life. 

The neonatal period is the first 28 days following delivery and is marked by growth and adaptation to breathing, suckling, digestion, and elimination. Unfortunately, it is the most fragile period of life. The World Health Organization reports that death during this period happens due to inadequate or substandard care worldwide. While modern medicine reduces deaths, the CDC reported 5.4 deaths per 1,000 live births in the U.S. in 2020 alone. 

This article provides an overview of full-term newborn nursing care. Once we establish baseline information, we'll provide common newborn care plans you can use in your practice. 

Full-term vs. Preterm Infants

This article focuses on caring for full-term infants and their parents or caregivers. It's critical to understand the difference between a preterm and full-term pregnancy to establish your baseline understanding. 

The CDC defines preterm birth as babies born before 37 weeks gestation. About one in every ten births in the U.S. meet this definition. The last few months in utero are when critical growth and development of the lungs, liver, and brain happens. So, babies born before they reach full-term (39 weeks gestation) may experience life-threatening conditions. 

Importance of the Newborn Assessment

Nurses must begin their assessment the minute the baby is delivered. It's important to note that the assessment for preterm and full-term infants is essentially the same. However, care strategies and interventions vary significantly and must be individualized to the newborn's gestational age and the presence or absence of normal body functions. 

While a head-to-assessment is needed, nurses typically use one or more evidence-based assessments to establish the newborn's baseline function and overall well-being. Below are the most common assessments done during the nursing process at birth. Definitions of normal and abnormal findings are provided too.

Size Parameters

Healthy newborns come in all sizes. Standard size measurements obtained at birth include weight, length, and head circumference. 

Average newborns weigh between 7 and 7.5 pounds—however, a baby weighing between 5 pounds, 11 ounces and 8 pounds, 6 ounces is within normal limits. Low birth weight is any weight under 5 pounds, 8 ounces, and larger than average babies weigh over 8 pounds 13 ounces. 

Many factors can impact the newborn's weight, such as 

• Maternal health and nutritional status - Poor nutrition or overall health can affect the baby's growth and development
• Gestation - preterm newborns are typically smaller, and babies born past their due date may be larger at birth
• Maternal smoking - mothers who smoke often have smaller-than-average babies
• Gender - boys usually weigh more than girls at birth
• Family history - size and weight at birth may run in families
• Gestational diabetes - mothers who have diabetes during pregnancy commonly deliver larger-than-average newborns
• Multiples - pregnancies with more than one baby typically have lower birth weight infants

The average length of an infant at birth is between 19 to 20 inches. Full-term babies between 18.5 and 21 inches long are within normal length limits.

The last measurement obtained at birth is the frontal-occipital or head circumference. This standard nursing assessment indicates normal brain development and ranges between 13 and 14 inches at birth. Wrap a measuring tape around the broadest part of the infant's head to perform this measurement. The tape measure should be just above the eyebrows and ears and wrap around the back of the head where it slopes to the neck.  

Vital Sign Measurement

Nurses obtain complete vital signs immediately after birth as part of a thorough nursing assessment. 

Normal vital sign ranges include:

Temperature: 97.7 - 99.4 Fahrenheit (36.5 - 37.5 Celsius)
Pulse: 120-160 beats per minute
Respirations: 30-60 breaths per minute
Blood pressure: 75-50/45-30 mm Hg at birth

APGAR Scoring

The APGAR scoring happens at the first and fifth minutes of life and is a good predictor of neonatal mortality. This standard assessment is divided into five categories, each represented in the acronym: Activity, Pulse, Grimace, Appearance, Respiration/breathing. 

If the one-minute score is low, the nurse and healthcare provider will administer the appropriate interventions and treatments, such as oxygen or stimulation. Most babies improve by the five-minute assessment. However, if the baby's status has not improved at this time point, the nurse obtains a third APGAR score 10 minutes after birth. 

Scores between 7 and 10 are within normal limits. A score between 4 and 6 is moderately abnormal, and scores of 3 or below are concerning. Suppose the child's condition does not improve with standard interventions. In that case, the baby may require a higher level of care and be transferred to the neonatal intensive care unit for assessment by the pediatric nursing team. 

Each assessment category receives a score of 0 to 2 points, with the highest possible overall score of 10. It's normal for most babies to get a score lower than 10 during the first few moments of life because their hands and feet may appear blue as they learn to breathe outside the womb. 

Below is the rubric used during the APGAR scoring:

Activity/muscle tone

• 0 points - limp or floppy
• 1 point - limbs flexed
• 2 points - actively moving

Pulse/heart rate

• 0 points - absent pulse
• 1 point - pulse below 100 beats per minute
• 2 points - pulse over 100 beats per minute

Grimace

• 0 points: absent response to stimulation, such as suctioning of nares
• 1 point: facial movement or grimacing with stimulation
• 2 points: crying, coughing, sneezing, or withdrawing feet to stimulation

Appearance

• 0 points: full-body paleness, blue or bluish-gray skin color
• 1 point: pink body, but blue extremities
• 2 points: pink skin color all over

Respiration/breathing

• 0 points: absent breathing
• 1 point: weak cry, irregular breathing
• 2 points: strong cry

There is some hesitancy within the medical community regarding APGAR scoring. However, observing the baby holistically helps determine the nursing care plan and interventions. A low APGAR score may be related to the following: 

• Complicated deliveries
• Preterm infants
• Cesarean delivery

Standard Head-to-Toe Nursing Care

Standard newborn nursing care includes:

• Looking for signs of respiratory distress, such as wheezing, labored breathing, or apnea
• Assessing overall cardiovascular status, including heart rate and rhythm, and providing stimulation or positive pressure ventilation as needed
• Monitoring body temperature and drying and swaddling the infant to reduce heat escaping
• Performing APGAR scoring 
• Administering Hepatitis B and Vitamin K vaccination within 1 hour of delivery
• Measuring weight, length, and head circumference 
• Obtaining routine newborn blood tests via heel stick
• Initiating breastfeeding early
• Promoting skin-to-skin contact
• Assessing parent-child bonding

Nursing Diagnosis and Care Plans for Parents of Newborns

The nursing process, assessment, and interventions play a crucial role in the care of the newborn at birth. Nurses also provide care and support to the mother during the postpartum phase and provide education to help the new caregivers bond with and provide care to their infant. A delicate balance of skilled nursing care, empathy, and compassion can create a holistic and comprehensive care environment for everyone. 

Below are some of the most common nursing diagnoses for newborns. 

Nursing Diagnosis: Risk for Hypothermia

Keeping the newborn warm immediately following birth is essential. A high surface area to volume ratio makes losing too much heat easy. Low birth weight infants are at an increased risk and may experience rapid heat loss and hypothermia if nursing interventions to combat the problem are not instituted quickly. 

Potentially Related To

• High surface area to volume ratio
• Pre-term birth
• Low birth weight
• Presence of infectious disease
• Thin skin that allows heat loss
• Lack of shiver response to increase warmth
• Inadequate subcutaneous fat stores
• Inadequate thermoregulation function
• Cesarean delivery

Evidenced By

• Low body temperature

Desired Outcomes

• The patient will maintain a body temperature within normal limits.
• The parents/caregivers will demonstrate proper dressing and swaddling techniques.
• The parents/caregivers will verbalize normal body temperature and ways to prevent heat loss. 

Risk for Hypothermia Nursing Assessment

1. Assess the body temperature. 
2. Monitor for risk factors, such as preterm birth, low birth weight, and infection.
3. Assess for signs of cold stress.

Risk for Hypothermia Interventions and Rationales

1. Dry the newborn, dress, and swaddle in a warm blanket. 
Rationale: Wet skin from birth increases heat loss and feelings of coldness. Swaddling helps to hold in warmth and maintain body temperature.

2. Utilize isolettes and radiant warmers as needed.
Rationale: Provides external warming to combat heat loss.

3. Cover the head with a cap. 
Rationale: Prevents heat from escaping from the head, which is a large percentage of the newborn's body surface.

4. Educate the parents/caregivers on keeping the newborn warm. 
Rationale: Assists in the successful transition to parenting and helps with thermal regulation after birth.

Nursing Diagnosis: Risk for Impaired Gas Exchange

Newborns must adapt to their new environment quickly. This adaptation relies heavily on the lung's ability to breathe normally outside the uterus. Unfortunately, prematurity, congenital disabilities, and acquired infections can impair the lung's ability to maintain gas exchange within normal limits. 

Because a newborn's respiratory status can lead to heart failure, nurses must promptly perform a thorough respiratory assessment and provide needed interventions. 

Potentially Related To

• Increased metabolic rate due to change of environment at birth
• Poor lung function
• Reduced functional residual capacity
• Cold stress at birth
• Excess mucus secretions in the respiratory tract

Evidenced By

• Abnormal breathing
• Nasal flaring
• Cyanosis
• Hypoxemia
• Retractions

Desired Outcomes

• The patient will maintain ABGs within normal limits.
• The patient will maintain oxygen saturation within normal limits.
• The patient will maintain respiratory patterns and effort within normal limits.

Risk for Impaired Gas Exchange Nursing Assessment

1. Conduct a thorough respiratory assessment. 
2. Monitor ABGs, pulse oxygenation, and other blood tests for signs of circulatory, respiratory, or metabolic problems.
3. Monitor for nasal flaring, retractions, grunting, and other signs of labored breathing. 
4. Assess the parent's understanding of the infant's respiratory status.
5. Assess the parent's understanding of signs of respiratory distress. 

Risk for Impaired Gas Exchange Nursing Interventions and Rationales

1. Suction the airway.
Rationale: Removes secretions to allow for easier breathing

2. Administer oxygen.
Rationale: Improves gas exchange.

3. Stimulate the infant.
Rationale: Wakes the baby up and stimulates breathing.

4. Assess the need for mechanical ventilation.
Rationale: Provides external breathing mechanism if the child lacks respiratory drive. 

Nursing Diagnosis: Risk for Infection

A newborn's immune system is immature for the first few months of life. This immaturity increases the risk of contracting infections and may allow infectious processes to become life-threatening quickly. 

Therefore, the nurse must assess for signs and symptoms of infection and educate parents and caregivers on ways to keep the infant safe while the immune system continues to develop.

Potentially Related To

• Inadequate immunity
• Exposure to pathogens in the environment
• Traumatized tissues
• Decreased action of the cilia in the lungs
• Inadequate immune response in the blood system
• Trauma at delivery
• Congenital anomalies
• Prematurity at birth

Evidenced By

• Increased WBCs
• Fever
• Localized signs of infection related to the primary site

Desired Outcomes

• The patient will be free of signs and symptoms of infection.
• The parents/caregivers will verbalize three ways to prevent infection.
• The parents/caregivers will demonstrate infection prevention strategies.
• The parents/caregivers will demonstrate proper hand hygiene before discharge home.

Risk for Infection Nursing Assessment

1. Assess the body temperature for signs of fever. 
2. Assess for congenital anomalies, prematurity, and delivery trauma.
3. Monitor for signs of infection. 
4. Assess for signs of immunity.
5. Assess the parent/caregiver's knowledge of infection control strategies.
6. Assess for early signs of sepsis or septic shock.

Risk for Infection Nursing Interventions and Rationales

1. Encourage breastfeeding. 
Rationale: Provides immunoglobulins to build up the newborn's immune system.

2. Follow infection control and hand hygiene protocols
Rationale: Decreases the risk of exposure to pathogens.

3. Educate the parents/caregivers on infection control and hand hygiene protocols.
Rationale: Decreases the risk of exposure to pathogens.

4. Administer antibiotics and other medications as prescribed for an actual infection.
Rationale: Treats causative pathogens. 

Nursing Diagnosis: Risk for Unstable Blood Glucose Levels

While infants must adapt to life outside the uterus, their time inside may still affect them for the first hours or days after birth. Blood glucose levels may be unstable just after delivery and can cause adverse effects on the child. Monitoring blood glucose levels and other signs and administering prescribed interventions is a critical role of the nurse. 

Potentially Related To

• Inadequate maternal nutrition during pregnancy
• Poorly controlled maternal diabetes
• Pancreatic tumors at birth
• Congenital metabolic diseases or disabilities
• Birth asphyxia
• Infection

Evidenced By

• Cyanosis
• Shakiness
• Apnea
• Hypothermia
• Lethargy
• Poor muscle tone
• Seizures
• Lack of interest in breast or bottle feeding

Desired Outcomes

• The patient will maintain a blood glucose level within normal limits. 

Risk for Unstable Blood Glucose Levels Nursing Assessment

1. Educate the mother and other caregivers on maternal risk factors and the need for blood glucose instability monitoring at birth.
Rationale: Promotes understanding and involvement in the newborn's care.

2. Encourage early breast or bottle feeding.
Rationale: Prevents and treats hypoglycemia.

3. Administer glucose supplements as ordered. 
Rationale: Prevents and treats hypoglycemia.

4. Educate parents/caregivers on signs of low blood glucose. 
Rationale: Promotes care of the newborn and caregiver-child bonding.

Nursing Diagnosis: Ineffective Breastfeeding

Breastfeeding benefits both the mother and the newborn. Breast milk provides needed nutrients and antibodies, protects against infant illnesses, and reduces the mother's risk of high blood pressure and ovarian cancer. 

It's essential to honor each family's decision about breastfeeding while educating them on the benefits. Some mothers may struggle to produce milk or experience mastitis and other complications that can make breastfeeding challenging. Be sure to provide support, empathy, and education together because other factors may outweigh the desire to breastfeed. 

Potentially Related To

• Poor or weak suck reflex
• Preterm infant
• History of maternal breast surgery
• Congenital anomaly prohibiting sucking or swallowing
• Lack of knowledge about the importance and benefits of breastfeeding
• Lack of family or partner support

Evidenced By

• Newborn crying during breastfeeding attempts
• Newborn pulling away or arching away from the breast during feeding
• Newborn crying or rooting within one hour of feeding
• Inadequate breast milk production
• Poor or resistant latching
• Insufficient weight gain
• Too few wet and dirty diapers
• Sore nipples past the first week of life

Desired Outcomes

• The infant will achieve effective breastfeeding.
• The mother will verbalize breastfeeding difficulties and seek assistance.
• The mother will be free of signs of mastitis or other infections.
• The infant will be satisfied after breastfeeding.
• The mother will verbalize feeling comfortable with breastfeeding techniques.

Ineffective Breastfeeding Nursing Assessment

1. Assess the structure of the mother's breast and nipples for abnormalities.
2. Assess the mother's knowledge of lactation and breastfeeding.
3. Assess the mother's milk flow. 
4. Assess for family or significant other support. 
5. Assess the infant's ability to latch onto the breast. 
6. Assess the infant's suckling reflex. 
7. Assess for newborn abnormalities that impact feeding, such as cleft lip or palate.

Ineffective Breastfeeding Nursing Interventions and Rationales

1. Educate parents/caregivers on lactation and breastfeeding.
Rationale: Promotes understanding and sets realistic expectations.

2. Educate parents/caregivers on the correct infant positioning during breastfeeding.
Rationale: Promotes successful breastfeeding.

3. Provide a calm and quiet atmosphere during breastfeeding.
Rationale: Reduces distractions and helps the mother relax, which assists with releasing breast milk. 

4. Educate parents/caregivers on burping the infant after every breastfeeding session.
Rationale: Prevents reflux and feeding-related discomfort in the infant.

Nursing Diagnosis: Ineffective Infant Feeding Pattern

The nurse in the labor and delivery room plays an integral role in the timing of the first breastfeeding session, which should be within the first few minutes of life. Initial breast milk, called colostrum, is packed full of disease-fighting nutrients which help the newborn's immune response.

As the nurse, you might notice difficulty with this first feeding. However, most of the time, ineffective feeding patterns take hours or days to appear. The newborn may have trouble coordinating their suck/swallow responses, leading to poor oral intake that doesn't meet metabolic needs. Early detection of ineffective feeding patterns reduces the risk of poor weight gain and often prevents the parent/caregiver's decision to stop breastfeeding prematurely. 

Potentially Related To

• Defects of the soft palate
• Prematurity
• Neurological impairment or delay
• NPO status of the infant

Evidenced By

• Maternal reports of poor latch and feeding schedule
• Infant weight loss

Desired Outcomes

• The infant and mother will establish a feeding routine within normal limits.
• The mother will demonstrate strategies to deal with an ineffective feeding pattern.
• The infant will gain weight.

Ineffective Feeding Pattern Nursing Assessment

1. Observe breastfeeding sessions for difficulty.
2. Assess for defects of the soft palate.
3. Monitor the number of wet and dirty diapers.
4. Monitor for weight loss.
5. Ask the parents/caregivers about feeding patterns.

Ineffective Feeding Pattern Nursing Interventions and Rationales

1. Minimize stimulation during breastfeeding sessions.
Rationale: Reduces stimuli that can interrupt the infant's feeding. 

2. Offer alternative methods of feeding as needed. 
Rationale: Maintains infant weight. 

3. Educate the parents/caregivers on alternate feeding positions.
Rationale: Provides knowledge of alternate positions that may ease the stress on the parents and infant. 

4. Instruct the parents/caregivers to keep a feeding journal. 
Rationale: Provides information about the feeding patterns over time.

Nursing Diagnosis: Risk for Neonatal Jaundice

Many infants experience hyperbilirubinemia at birth due to the immaturity of the liver. Usually, the liver filters bilirubin from the blood and gets rid of it through the intestines. However, a newborn's immature liver cannot perform this function, which causes excess bilirubin in the blood. As a result, hyperbilirubinemia causes a distinct yellowing of the skin that usually appears within the first few days of life. 

Jaundice in the newborn usually resolves independently or with at-home treatments, such as placing the baby in direct sunlight. However, in rare cases, neonatal jaundice is caused by an underlying disease or congenital anomaly that cannot resolve without surgery, medications, or other interventions. 

Potentially Related To

• Hyperbilirubinemia
• Rh incompatibility
• Prematurity
• Breastfeeding
• Immature liver
• Neonatal sepsis
• Liver disease
• Biliary atresia
• Abnormal red blood cell function

Evidenced By

• Yellow skin tone
• Yellowing of the whites of the eyes
• Dark yellow urine
• Pale colored stools
• Lethargy
• Poor feeding
• Inadequate weight gain

Desired Outcomes

• The infant will be free of signs of hyperbilirubinemia.

Risk for Neonatal Jaundice Nursing Assessment

1. Examine infant skin color in a well-lit room. 
2. Blanch the skin to assess the color.
3. Monitor bilirubin blood levels and Coomb's test lab values.
4. Educate on the need for liver and bile duct ultrasound, if indicated.

Risk for Neonatal Jaundice Nursing Interventions and Rationales

1. Administer phototherapy as ordered.
   Rationale: Special lighting that produces blue-green light alters the structure of the bilirubin molecules and promotes excretion, lowering blood levels.
2. Administer IVIG as prescribed.
   Rationale: Alleviates jaundice in Rh incompatibility.
3. Administer blood transfusions as prescribed.
   Rationale: Dilutes bilirubin levels in the blood.
4. Educate the parents/caregivers on the condition and interventions to take at home.
   Rationale: Promotes parent/caregiver's ability to care for the child at home independently.
5. Encourage frequent feeding sessions.
   Rationale: Lowers bilirubin levels by flushing it out of the infant's system.

Nursing Diagnosis: Impaired Parent/Newborn Attachment

While most parents bond quickly with their newborn, some experience a disruption of the interaction between the parent or caregiver and the infant. This disruption can lead to impaired attachment and a limited or absent bond between the two. In addition, a lack of connection between the caregivers and the infant at birth can create problems in the newborn, such as poor feeding patterns, weight loss, and feelings of abandonment that can have long-lasting effects. 

The nurse has a frontline view of the parent/child connection at birth. It's critical to observe this connection closely, provide support, and educate the parents as needed. 

Potentially Related To

• First-time parenting
• Knowledge deficit of newborn care
• Parent/caregiver anxiety
• Psychological or cognitive impairment of the parent/caregiver
• Post-partum depression
• Poor health of the parent or child at birth

Evidenced By

• Inadequate infant soothing offered by the parent/caregiver
• Lack of bond between the two
• Physical distance between the parent/caregiver and child
• Poor feeding, weight loss, or infant failure to thrive

Desired Outcomes

• The parent/caregiver will demonstrate acceptable parenting behaviors.
• The parent/caregiver will provide a secure environment for the child.
• The parent/caregiver will attempt skin-to-skin contact and other strategies to connect with the child.

Impaired Parent/Newborn Attachment Nursing Assessment

1. Observe the parent/child connection.
2. Assess the parent/caregiver's response to the infant.
3. Asses the infant for signs of overall well-being, such as weight gain. 

Impaired Parent/Newborn Attachment Nursing Interventions and Rationales

1. Provide time for the parent/caregiver to discuss any fears, worries, or needs about the relationship with their newborn. 
   Rationale: Encourages open and honest conversation so you can create a holistic plan for the parent/caregiver and child. 
2. Offer praise and support when you observe a parent/child bond. 
   Rationale: Offers support and encouragement for acceptable behaviors.
3. Encourage skin-to-skin contact at birth and continuing throughout the first few weeks or months of life. 
   Rationale: Promotes parent/child bonding.
4. Offer community-based classes on parenting as needed.
   Rationale: Provides ongoing education and support and positive parent/child bonding examples.
5. Educate the parents/caregivers on routine care of the newborn.
   Rationale: Bridges any potential knowledge gap regarding infant care. 
6. Educate parents/caregivers on normal newborn development. 
   Rationale: Provides knowledge of normal and abnormal development and when to seek additional support or treatment. 

More Newborn Diagnoses

Other nursing care plans that may be appropriate for newborn care include:

• Risk for hyperthermia
• Imbalanced nutrition: less than body requirements
• Compromised family coping
• Risk for injury
• Deficient fluid volume
• Failure to thrive

Newborn NCLEX Test Questions

It's never too early to take practice NCLEX test questions. A few questions about newborn care you practice with are below.

1. Which option below best describes how to assess an infant's palmar grasp reflex?
   a. Gently stroke the infant's cheek and assess if the head turns.
   b. Stimulate the sole of the foot by stroking from the heel upward. 
   c. Stroke the inside of the infant's hand, assessing if the fingers close around the object, providing stimulation. 
   d. Assess if the infant moves the legs in a stepping motion when held upright with the feet touching a surface.
2. An average heart rate at birth is:
   a. 120 beats per minute
   b. 60 beats per minute
   c. 220 beats per minute
   d. 75 beats per minute
3. Which statement below best represents how to obtain an infant head circumference measurement?
   a. Wrap the tape measure around the infant's head at the level of the eyebrows.
   b. Place a tape measure just under the ears and wrap it around the head.
   c. Wrap a measuring tape around the broadest part of the infant's head, just above the eyebrows, ears, and around the back of the head where it slopes to the neck.
   d. Place the tape measure at the mid-point of the ears, above the eyes, and at the base of the skull. 

Additional Readings and Resources

Did you know AllNurses has more content on newborns and related topics? Check out these great articles below:

• Tips for Newborn Screenings
• Assessing a newborn being held by mom
• NICU Nurse's Guide to Respiratory Distress Syndrome

Wrapping Up

Newborn care is an exciting area of nursing care. You get to witness the miracle of life repeatedly and support parents and caregivers when they need it most. We hope these newborn nursing care plans help you in your nursing care journey! 

References:

1. https://www.CDC.gov/nchs/fastats/births.htm
2. https://www.who.int/europe/news-room/fact-sheets/item/newborn-health
3. https://www.CDC.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
4. https://www.CDC.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm
5. https://onlinelibrary.wiley.com/doi/abs/10.1111/PPE.12360
6. https://www.sciencedirect.com/science/article/abs/pii/S0300957220302136
7. https://my.clevelandclinic.org/health/diseases/21053-rh-factor
8. https://med.stanford.edu/newborns/professional-education/jaundice-and-phototherapy/the-coombs--test.html