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Maternal Newborn Nursing

24.3 Newborn Discharge Planning and Parent Education

Maternal Newborn Nursing24.3 Newborn Discharge Planning and Parent Education

Learning Objectives

By the end of this section, you will be able to:

  • Summarize individualized parent teaching that will enhance parents’ confidence and abilities to care for a newborn during the first month at home
  • Verbalize safety needs of the newborn
  • Identify activities that parents should include in the activities of daily living for the newborn

Many new parents enjoy their time in the hospital after giving birth. It is a time to relax, get to know their newborn, and begin their lives together as a family while having the comfort and convenience of nursing staff to assist with care issues and needed education. Other parents feel just the opposite. These new parents are anxious to be discharged with their newborns to begin their lives as a family in the comfort of their home. Education in anticipation of discharge of the normal newborn is the topic of this section.

Ideally, discharge teaching, also referred to as parent education, should begin after delivery. If the nurse waits until discharge to begin the parent education, the amount of information can be overwhelming for the parents. Much of the information may be forgotten or lost in the flurry of activity that surrounds an infant’s homecoming. Because hospital stays are relatively short after childbirth, providing necessary parental education can be challenging to the nurse, who must be organized and persistent in education efforts. Nurses use various educational methods, such as videos, classes, and educational handouts available in various languages, to supplement their discharge education sessions. Additionally, some hospitals provide an educational channel on TV featuring parenting videos that demonstrate infant bathing, feeding, use of car seats, and other necessary skills. Hospitals may also provide websites with additional information and support for patients. After discharge, referrals for visitation by home care nurses may be an option for follow-up care, as well as support groups, when necessary.

Parent Education about Newborn Behaviors

Often, new parents do not know what is considered “normal” or expected behavior for a newborn. Even parents who have other children at home may not know or remember what to expect. Babies develop at different rates, but they all engage in many of the same behaviors and behavioral patterns. Parents appreciate anticipatory guidance from nurses regarding continuing infant care. Being given the tools to recognize and understand behaviors and patterns demonstrated by their newborns provides parents with a sense of accomplishment and control in their newly acquired roles. It also allows them to move forward in the bonding process with less worry and more confidence.

Breathing Patterns of the Newborn

Often a concern for new parents is their newborn’s breathing pattern: the rate and rhythm of breathing, which in the newborn is “regularly irregular.” Because newborns often have irregular breathing patterns, their breaths should be counted for a full minute, preferably when they are quiet and at rest. They are noisy breathers who have been known to squeak, gurgle, grunt, and whistle while breathing “normally.” Newborns are obligate nose breathers, and synchronous abdominal movement occurs with each breath. Chest movement is symmetric and not labored. But newborns can experience occasional periods of irregular respirations in which they may stop breathing for 5 to 10 seconds and then start breathing again on their own without any intervention. This is considered an expected breathing pattern for a newborn (Mohr et al., 2015). Parents should be informed about these periods of irregular breathing so that they do not worry unnecessarily. If their baby stops breathing for more than 10 seconds or begins to turn blue, they should call their provider or take their baby to the nearest emergency department. When an infant stops breathing for 20 seconds or more and develops cyanosis and bradycardia, the infant is said to have apnea.

Sleep Patterns of the Newborn

The nurse educates the new parent on expected newborn sleeping patterns prior to discharge. Many parents do not know how to recognize the signs of sleep readiness in their newborns, how long a newborn may sleep in a day, or what sleep position is best for their baby. The nurse can answer these questions and more.

Although every baby is different, most will show one or more of the following signs when they are ready for sleep:

  • rubbing eyes
  • yawning
  • looking away, ignoring behavior
  • fussing, irritability, possibly crying (depending on how long the other signs are ignored)

These are also signs of overstimulation. These signs will progress if they are ignored. That is, the initial behaviors will become fussing, then fussing will progress to irritability, irritability will become crying, and crying will worsen to inconsolable crying (Kim, 2011).

Not every baby knows how to put themselves to sleep. Many parents want to rock their baby or breast-feed their baby to sleep. Most experts recommend establishing a bedtime routine, and they suggest not putting a baby to sleep in a parent’s arms or while feeding. A bedtime routine may include a bath, soft music, turning the lights down, reading a bedtime story, or rocking in a chair. If the baby were to go sleep only while being held, this would become a habit. The baby could quickly learn to expect this behavior and not go to sleep on their own. Most experts recommend placing the baby into their sleep space while still awake. This will help the baby learn to go to sleep on their own or will help condition the newborn to establish sleep time behaviors.

The average newborn sleeps approximately 16 to 17 hours per day, but this can vary greatly. Some may sleep close to 20 hours a day. Generally, they sleep about 8 to 9 hours in the daytime and about 8 hours at night. Most babies do not begin sleeping through the night (6 to 8 hours) without waking until they are at least 3 months of age or weigh 12 to 13 pounds (Raising Children Network, 2023; Stanford Medicine, 2023c). Once again, this will vary greatly depending on the infant. Some babies will not sleep through the night until they are closer to a year old. Newborns and young infants have small stomachs and need to be fed often. The infant’s age as well as what they are being fed will determine how often they wake to be fed. For instance, breast-fed infants need to be fed more frequently than formula-fed infants because breast milk is digested more easily and therefore more quickly than formula. In most cases, the infant will awaken and be ready to feed every 3 hours or less with an average of 8 to 12 feedings per day.

Babies will generally set their own sleep patterns. Parents should be educated that if their baby is sleeping consistently and suddenly begins waking, it might be an indication of a growth spurt, a developmental change, or overstimulation. If it continues and their infant shows other signs such as pulling or rubbing their ear or unusual irritability, they should consider notifying their health-care provider for a possible ear infection or other problem.

Infants do not sleep as deeply as adults, spending approximately 50 percent of their time in REM (rapid eye movement) sleep (Raising Children Network, 2023). In REM sleep, babies often make noises loud enough to wake parents in the same room. They may also move about in their crib as if they are about to awaken. Going to them at this time will surely awaken them because they are in a very light sleep. If left alone, infants may return to a quiet sleep. It is not uncommon for babies to experience these cycles as they pass from deep sleep to light sleep in the first few months of life.

Growth and Development Patterns of the Newborn

During the first year, an infant goes through a time of rapid change. Their birth weight usually doubles by about 4 to 6 months and triples by the end of their first year (Boston Children’s Hospital, 2023). During this period, they grow approximately 1 foot in height. At about 6 months, teeth begin to erupt; and by the end of their first year, they have between 6 and 8 deciduous teeth. Their physical growth and development are largely dependent on the birthing parent’s prenatal nutrition and the quality and type of feeding in infancy. The changes in body proportions mirror changes in developing internal organs. The nervous system demonstrates increased control over body movements, which allow infants to sit, stand, and walk, usually taking their first steps around 1 year old. Generally, walking is mastered sometime between 12 and 18 months, and many infants walk much earlier. Sensory function also improves, allowing infants to discriminate visual images, sounds, and tastes. Kidney and liver function helps older infants excrete drugs or other toxic substances much more efficiently than newborns do.

Cognitively, the brain continues to increase in complexity during this time. Most of the growth involves maturation of cells. For example, a newborn’s eyes may widen in response to a sound, whereas a 1-year-old will turn their head to the sound and recognize its significance. A 2-month-old cries and coos, and a 1-year-old says a few words and understands many more. A 6-week-old infant grasps a rattle for the first time while a 1-year-old infant reaches for toys and self-feeds. Infants receive input from the environment from birth onwards, and as they age, their internal cognitive abilities continue to mature, as does the ability of their growing brain to interpret external stimuli (State of Michigan, 2023).

Parent Education about Safety of the Newborn

Supporting parents, particularly new parents, as they prepare to go home involves education and forethought regarding the future developmental needs of the newborn. It is normal for parents to feel a mix of excitement and fear when caring for a newborn at home for the first time, or even the tenth time. This section focuses on parent education surrounding the safety of the newborn.

Safe Sleep Practices

Parental education is essential regarding safe sleep practices. Approximately 3,500 preventable infant deaths occur each year in the United States due to unsafe sleeping arrangements (CDC, 2024). The unexplained death, usually during sleep, of a seemingly healthy baby that is less than a year old is called sudden infant death syndrome (SIDS) (Mayo Clinic, 2022a). The cause of SIDS is unknown, but it may be associated with defects in the infant’s brain that control breathing and arousal from sleep (Mayo Clinic, 2022a).

Although SIDS can strike any infant, research has identified the following potential risk factors (AAP, 2022a; Mayo Clinic, 2022a; Moon et al., 2016):

  • Sex—Boys are slightly more likely to die of SIDS.
  • Age—Infants are at the highest risk for SIDS between the 2nd and 4th months of life.
  • Race—Non-White infants are at a higher risk for developing SIDS.
  • Family history—Infants who have had a sibling or a cousin die of SIDS are at a higher risk of SIDS.
  • Secondhand smoke—Infants who live with smokers or are exposed to secondhand smoke are at a higher risk for SIDS.
  • Prematurity—Both prematurity and low birth weight increase an infant’s chances of SIDS.

To reduce the risk of SIDS, it is important not to overheat the infant. Advise parents to use an infant sleep sack or other sleep clothing to keep their baby warm rather than additional blankets (see Figure 23.20). When possible, breast-feeding is recommended for at least 6 months because it lowers the risk of SIDS (AAP, 2022a; Mayo Clinic, 2022a). Offering the baby a pacifier without a strap or string at naptime and bedtime may also reduce the risk of SIDS (AAP, 2022a; Mayo Clinic, 2022a). Parents should also make sure that the infant continues with routine immunizations. Some research reports that routine immunizations reduce the risk of SIDS. Parents should not use products for sleep that are not specifically marketed for infant sleep.

According to the CDC (2024) and the American Academy of Pediatrics (2022a), parents should follow these recommended guidelines to keep infants safe while sleeping:

  1. Place the baby on their back for all sleep times, naps, and at night. Supine is the safest position to place a newborn to sleep.
  2. Always use a firm sleep surface, such as a safety-approved mattress and crib. The sleep surface should be flat and non-inclined.
  3. Eliminate all soft bedding, blankets, pillows, crib bumper pads, soft toys, and stuffed animals from the baby’s sleep space.
  4. Have the baby share the parent’s room, but not their bed.

Safe Transportation

The American Academy of Pediatrics most recently updated its car-seat guidelines in 2018 (Durbin & Hoffman, 2018). All 50 states require the restraint of infants and young children in car seats when they are riding in automobiles (Durbin & Hoffman, 2018). The nurse should teach parents that the safest place for their baby in the car is in a rear-facing infant safety seat located in the middle of the back seat. An infant that is held by an adult in a moving vehicle, even if that adult is wearing a safety restraint, is not safe.

Infant and child safety seats are essential to reduce injury and death to infants and children when accidents occur. Infants and toddlers are at greater risk for head and spinal cord injuries if they are in a forward-facing car seat instead of a rear-facing car seat, which provides better head and neck support (Durbin & Hoffman, 2018). Infants should remain in the rear-facing car seats for travel until they reach the highest weight or height allowed by the seat’s manufacturer. Most infant-specific car seats range from birth to 1 year or a weight less than 20 lb (9 kg) (Durbin & Hoffman, 2018). The car seat must be latched at 2 points to the car at the base of the car seat. Once installed, car seats should not move more than 1 inch side to side or front to back by regulation. Most local police, hospitals, and fire departments can advise parents where to have car seats fitted locally.

An infant discharged from the hospital is placed into a rear-facing infant car seat in the back of the automobile by a parent. Many hospitals do not permit staff to place the infant in the car seat due to potential liability. Some hospitals have technicians who are specially trained to determine if car seats are installed properly and if they have been correctly fitted to the newborn. It is generally up to the parent to see that the car seat has been properly installed prior to hospital discharge. New car seats come with detailed instructions for installation in the packaging, but most local police and fire stations offer car seat installation services free of charge with appointments.

Infant CPR Caregiver Education

The American Heart Association has long claimed that the sooner cardiopulmonary resuscitation (CPR) is begun after a cardiac event is witnessed, the better the chances of reviving the person will be. Each second that the heart is not pumping oxygen-rich blood to the brain and organs, brain cells are lost. Infant CPR training is often offered to parents after birth and prior to discharge from the hospital in the form of CPR videos, written materials, or physical classes or instruction. Other hospitals offer Infant CPR Anytime Kits to parents prior to their discharge. These kits give parents the opportunity to learn infant CPR in the hospital setting with an infant manikin that they can take home with them to practice on. The whole self-instruction course takes about 20 minutes to complete, and parents have nurses to help if they have any questions (American Heart Association, 2023). The fact that caregivers can practice at home helps them become more confident in the skills and more likely to act should an emergency occur, and CPR be needed.

Preventing Newborn Injury

Hundreds of infants younger than 1 year old die every year in the United States because of injuries—most of which could have been prevented (AAP, 2017). Injuries often occur because new parents are not aware of what their newborns can do, such as rolling off a bed or grabbing a hot cup of coffee. Therefore, parental education about newborn/infant safety issues is an important responsibility of the nurse during the postpartum period and throughout the first year of life. The most common accidents are falls, burns, choking, and suffocation.

Babies wiggle, move, and push against objects from the moment they are born. In fact, they have been practicing these movements in utero for months. Even these very first movements can result in accidental falls. Nurses should remind parents to be especially cautious when the infant is wet after bathing or when in the arms of a sibling. Newborns should never be held by a young unsupervised child due to babies’ sudden, unpredictable, and jerky movements. Caregivers should not leave the baby alone on changing tables, beds, sofas, or chairs. As the infant grows and can roll over, they may fall off unless protected. When the baby is not being held, they should be placed in a safe spot, such as a crib, play yard, or infant seat. Infants can crawl as early as 6 months (AAP, 2017). Parents or caregivers should be advised to use gates on staircases and to close doors to rooms where infants may get injured. Parents should install window guards on all windows above the first floor. Baby walkers should not be used because they can tip over, and the baby could be injured. In addition, an infant in a baby walker can fall down the stairs, causing serious head injuries. If the infant falls and does not act normally after the fall, parents should call the health-care provider or take the child to the emergency department.

Nurses should educate parents never to carry the baby and hot liquids, such as coffee, tea, or soup, at the same time. The baby could easily be burned. Also, parents should check the baby’s bath water prior to putting the baby in it. If the infant is burned, immediately put the burned area in cold water, keeping it in cold water for several minutes to cool it off. Then, parents should cover the burn loosely with a dry bandage or clean cloth and call their doctor. If the burned area is blistering, parents should take the baby to the emergency department immediately. House smoke alarms should be checked every month for battery life, and batteries should be changed every year unless long-life batteries are installed.

Babies explore their world by putting everything into their mouths whether it is edible or not. Nurses should remind parents never to leave small objects in the baby’s reach, even for a short time. Parents of a newborn should be educated about the risks of suffocation and instructed to not leave loose blankets in the baby’s sleep area. They also need to be informed to keep all plastic wrappers and plastic bags away from their infants because these can form a tight seal covering the mouth and nose and can suffocate the infant. Many hospitals and pediatric offices will provide parents with instruction on how to care for a choking infant.

About Activities of Daily Living with a Newborn

Relationships between parents and their child begin before birth and continue throughout the lifespan. Attachment is a strong emotional bond that can begin in the newborn period when the baby is first introduced to their birthing parent after birth. Immediately after birth, newborns are typically in a quiet alert state when they are receptive and follow the parent’s face carefully with their eyes. This first interaction fosters bonding between the birthing parent and the baby. For many families, this experience also involves bonding with the other parent and the siblings. In the first months of life, the newborn quickly learns about food, safety, and security. When those needs are met, the newborn learns to trust the people who provide needed care and to explore their environment more actively. During periods when the baby is more alert, they will focus on the faces of their caretakers and learn the positive aspects of interpersonal relationships. Before long, the newborn will be trading smiles, making faces, sticking out their tongue, laughing, and imitating behaviors.

Educating Parents on How to Soothe a Newborn

Newborns may cry or fuss for several hours a day. It is their way of letting others know that they need or want something or that something is wrong. Crying peaks at approximately 6 weeks of age at about 3 hours per day. By 3 months, crying decreases to about 1 hour per day (Feigelman, 2016). Infants have no other way of communicating that their needs are not being met. Parents find infant crying most frustrating when they do not know why the baby is crying. When the cause of newborn crying is not obvious, parents often see it as a sign of their own inadequacies. Research has shown that when an infant’s needs are met consistently in a calm, warm, and prompt manner, trust begins to develop between the newborn and their caregiver. Additionally, infants who are held consistently when they are in distress have been found to cry less at 1 year of age and be less aggressive at 2 years of age (Sanford Health, 2022).

Often, parents can determine the cause of the infant’s distress by the nature of the crying. Newborns will cry when they:

  • are hungry
  • are tired
  • are too cold or too hot
  • need their diaper changed
  • have gas
  • are overstimulated
  • are bored
  • are sick

Sometimes, though, it is not possible to determine why a newborn is crying, and it may not be possible to comfort the baby. This need not be the fault of the parent or caregiver. If the newborn cries more than usual, cries at different times of the day than usual, or if the crying sounds different or more frantic than usual, it is a good idea to contact the health-care provider. These might be signs that the newborn is sick.

Treating Known Causes of Crying

If the infant is hungry and it has been more than 30 minutes since the last feeding, suggest that parents try feeding the baby. It is possible that an air bubble may have caused a feeling of fullness before the baby had completed the last feeding. The infant may also be going through a growth spurt and need more frequent feedings to provide the nutrients to support rapid growth. Remind parents of the signs of satiety so that they can avoid overfeeding, which will cause abdominal discomfort, fussiness, and potential spitting up.

Teach parents that when the infant is pulling up their legs or crying with bursts or intermittent screams of pain and kicking, it is likely that the baby is “gassy” and has gas or air bubbles. Fussy infants may need more frequent burping during and after feedings compared to other infants, regardless of whether they are breast-fed or bottle-fed. It is also helpful to burp during crying spells because the infant may swallow air then. Changing the baby’s position to lying prone across a parent’s lap (or over a warmed blanket) may help expel gas. Placing the infant in the supine position and gently flexing the knees on the infant’s abdomen may also help a gassy baby.

Most newborns do not seem to mind wet or soiled diapers but may fuss or cry if they get a chill or if their skin becomes irritated. It is best to set up a schedule for diaper changes, perhaps before every feeding, to help wake the infant fully. Teach parents that consistent diaper changes will help prevent skin irritations and rashes.

The nurse should show parents how to check the infant’s clothing for anything that could cause discomfort (buttons, zippers, tags, stiff collars or seams, tight elastics, etc.). Remind parents not to overheat the newborn. They should place the palm of their hand on the baby’s abdomen to feel the baby’s body. It should feel comfortably warm, not hot or cold, even if the infant’s feet and hands are slightly cool. The newborn should be dressed as warmly as the parent, with one additional layer, such as a receiving blanket or a sweater (American Academy of Pediatrics et al., 2019). Babies who are overdressed do not perspire but will cry instead to show their discomfort.

If the newborn is overstimulated—from too much noise, too many visitors, too many people “playing” with them, or too many lights—this can also be a cause for crying. Holding or swaddling the infant in a quiet, preferably darkened, environment and gently rocking, walking, or swaying the infant may prove helpful.

Soothing Techniques for Crying Newborns

The best advice to soothe a crying baby is to remain patient and calm. Most babies will calm and be comforted by gentle rocking, talking softly, or swaddling in a blanket (see Figure 24.10). Once the baby is calm, the caregiver can go about their investigation to find the cause of the initial crying.

When an infant is difficult to soothe, it can lead to parental frustration. When possible, the parent or caregiver should seek relief and have someone else attempt to soothe the baby. Friends and family members can assist as well. This will help to keep parents fresh, ease their frustration, and give them a chance to rest. Often, something as simple as a change in position when transferring the baby from one person to the next is enough to end a bout of crying. But there are times when infants cry inconsolably for long stretches of time, starting when they are around 2 weeks old and continuing until 3 to 4 months of age. Inconsolable crying can last up to 5 hours a day and is a normal part of development, termed the period of PURPLE crying (National Childbirth Trust [NCT], 2022). Each letter of PURPLE represents a characteristic of the crying: “P—Peak of crying, U—Unexpected, R—Resists soothing, P—Pain-like face, L—Long lasting, E—Evening” (NCT, 2022). Since 2007, the National Center on Shaken Baby Syndrome has run the Period of PURPLE Crying Program. It is an evidence-based program for the prevention of shaken baby syndrome/abusive head trauma (SBS/AHT). This program has a dual purpose:

  • offering support to parents and caregivers in understanding and coping with a baby's early heightened crying
  • working to decrease the frequency of SBS/AHT incidents. (National Center on Shaken Baby Syndrome, n.d.)

Unfortunately, a parent’s or caregiver’s feelings of helplessness, frustration, and anger are often closely related to their inability to cope with an infant’s inconsolable crying. Remind parents that if their efforts at soothing their baby are not working, it is all right to feel frustrated, and it is all right to ask for help. While it is hard to bear, infant crying is unavoidable. If parents are feeling overwhelmed and helpless, let them know that these are normal feelings. Have them place the baby down in a safe place and reach out for help before their frustrations cloud their judgment or impede their mental health. Instruct them to call a friend or family member to come and help them. If no one is available and the baby is in a safe place, they should step into another room and calm themselves before returning to the baby and trying again.

Instruct the parent or caregiver to contact the baby’s health-care provider immediately if the infant displays any of the following symptoms (Colicky crying, n.d.):

  • if nonstop crying lasts more than 2 hours
  • if the infant cries out when you touch, move, or hold them
  • if the infant looks or acts abnormal
  • if the infant has a temperature >100.4° F (38° C) or higher
  • if the infant has bulging or swollen fontanelles
  • if the infant has a swollen groin
  • if the infant is vomiting
  • if the infant refuses to drink or consumes very little for more than 8 hours

Educating Parents on Skin Care for the Newborn

Bathing their newborn is an experience that many new parents find terrifying at first and enjoyable after they are confident in their skills. The bath is a time for bonding and watching their newborn relax in the warm, soothing water. At least that is how it is supposed to be. But not all newborns enjoy the bath right away. The air is cold, and the water is a shock. The washcloth is rough, and the baby wash is cold. Babies do not quite know what to make of it, and it is not unusual for them to cry through the first few experiences with bathing.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Patient-Centered Care: Giving Baby a Bath

Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences.

Knowledge: Examine common barriers to active involvement of patients in their own health-care process.

Skill: Remove barriers to the presence of families and other designated surrogates based on patient preferences.

  1. Sponge baths are needed until the umbilical cord stump falls off. This will happen between 10 days and 2 weeks postpartum. Infection prevention is the primary reason for this. Sponge baths allow for normal healing to take place and for the cord to dry and fall off. Sponge bathing includes regular “wipe downs” of the face, hands, feet and genitals and any other areas that may be visibly dirty. Continue to give sponge baths once to twice weekly until the cord stump falls off.
  2. Once the cord falls off, plan on bathing the baby 1 to 3 times a week. More frequent bathing may dry and irritate the skin. Plan bath time for when the baby is well rested and not hungry.
  3. Bath products should be natural, unscented, and simple.
  4. Gather supplies before putting the baby in the bath. You will need a well-cushioned and well-supported baby tub, warm water in the tub or sink, bottles open and ready to pour, and washcloths and towels at the ready. Baby washcloths are very soft. Placing a bath pad or towel under the baby can help keep the baby in one spot.
  5. Fill the baby tub or sink with a few inches of warm water. You will want just enough water to cover the bottom of the baby’s body. To gauge the temperature of the water, use the inside of your wrist or elbow. It should feel warm, about 100° F (37.8° C).
  6. Thermoregulation is a primary concern with the newborn, who will have difficulty maintaining body temperature. Keep the baby covered during the bath. Even in a warm bath, the baby can lose body heat quickly. Use a warm washcloth to cover the baby and swap it out as needed.
  7. Go slowly and stay calm. The baby will stay calm if you are feeling relaxed. Make sure your setup feels relaxed to you before beginning the bath. Never, under any circumstances, leave a baby alone in the bath.
  8. Start washing the face first (no soap), then the rest of the body. Clean around their mouth, behind their ears, and under their chin, where milk and drool can hide in the folds. Rinse the washcloth and wash the rest of their body, getting into the creases and folds, under their arms and between their fingers and toes. When it comes to their genitals, wash girls from front to back and between their skin folds. For boys, uncircumcised or not, wipe their penis clean. Other than their face, use soap on the rest of their body, being sure to rinse it off completely so their skin will not dry out.
  9. Skip the lotions and powders unless advised. Babies normally have dry, peeling skin that will soften on its own after peeling. Lotions or creams are unnecessary and may cause skin irritation. When the bath is completed, wrap the baby in a warm, soft towel and cuddle them close. Dry them and dress them warmly. Be sure to cover their head to avoid heat loss until their hair is dry.

Attitude: Respect patient preferences for degree of active engagement of care.

When to Take a Baby’s Temperature

It is often difficult to discern when a baby has a fever or when to take a newborn’s temperature because their behavior can often mimic normal newborn behavior. Caregivers need to be cognizant of the signs and symptoms of a fever in infants and be mindful if these changes in behavior occur. When they are observed, the baby’s temperature should be taken. Behaviors often indicative of newborn fever are the following (Mayo Clinic, 2023a):

  • Crying or fussiness—If occurring more than usual, this is often the first sign of fever or illness.
  • Excessive fatigue—If the newborn would rather sleep than eat, it might be a sign of fever or illness.
  • Decreased appetite—If the infant is not waking for meals or eating with their usual appetite, check their temperature.
  • Cold/Flu symptoms—If the baby has developed a cough or congestion, check their temperature. (Then notify the pediatrician.)
  • Spitting up—If the baby is spitting up more frequently and in excess quantities, this could point to vomiting rather than spitting up.
  • Feeling warm—It can be hard to gauge the temperature of your baby, especially on a warm day. Taking their temperature internally, that is, rectally (rather than just feeling their forehead) is the best way to be sure.
  • Pulling at ear—Ear infections can cause discomfort in the ears. Because babies cannot communicate with words, pulling at their ear is a tell-tale sign that they are feeling pain or discomfort in that area. Take their temperature.
  • Rash—Any type of rash should be evaluated by your pediatrician, especially if your baby has been exposed to or has chickenpox symptoms. Take their temperature.

The preceding situations are examples of when to take a baby’s temperature, but they are not exclusive. Simply stated, when in doubt, take the baby’s temperature.

Educating Parents about Taking a Baby’s Temperature

Digital thermometers make taking a baby’s temperature quick and easy. The nurse should teach parents to always use a digital thermometer to check a baby’s or infant’s temperature. Never use a glass mercury thermometer because health and safety risks are inherent with their use. If parents report having a glass thermometer, the nurse should instruct them to take it to their pharmacy or health department for proper disposal.

For babies and toddlers up to 3 years of age, the American Academy of Pediatrics recommends taking the temperature rectally using a rectal thermometer placed in the baby’s anus (Johns Hopkins Medicine, 2019). This method is accurate and gives a quick reading of the baby’s internal or core temperature. Teach parents that oral and rectal thermometers have different shapes and should not be used interchangeably. Using oral thermometers rectally can cause damage. A rectal thermometer has a round rather than an elongated security bulb at the insertion end specifically for safely taking rectal temperatures.

To take a baby’s rectal temperature, the parent should place the baby across their lap or on a changing table, on their abdomen, facing down. Next, they place their hand nearest the baby’s head on their lower back and separate the baby’s buttocks with their thumb and forefinger. Using the other hand, they gently insert the lubricated end of the thermometer ½ to 1 inch, or just past the anal sphincter muscle. The thermometer should be pointed toward the infant’s umbilicus or belly button. The parent should hold the thermometer with one hand on the baby’s buttocks so that the thermometer will move with the baby. The parent uses the other hand to comfort the baby and prevent moving. Caution parents never to leave a baby unattended with a rectal thermometer inserted. They should hold the thermometer until it beeps or signals, remove the thermometer, wipe the bulb, and read and immediately record the temperature. The thermometer can be cleaned with soap and water or rubbing alcohol. If the baby has a rectal temperature of 100.4° F (38° C) or higher, parents should call the baby’s health-care provider (Johns Hopkins Medicine, 2019).

An axillary temperature is taken under the arm (in the armpit). If parents are more comfortable checking the infant’s temperature this way, they must be careful that none of the infant’s clothing gets between the thermometer and the skin. The thermometer should have skin touching it on all sides. Axillary measurement may be used as a “screening” method to get an idea of whether an infant is febrile. If it shows a fever, a more accurate measure should be utilized. Digital thermometers are used for axillary measurement.

A tympanic thermometer uses an infrared ray to measure the temperature inside the ear canal. This method may not be accurate for newborns or any infant under a year old. Parents should refer to the manufacturer’s recommendations. These thermometers need to be positioned very carefully within the ear canal to get a precise reading, which is not possible in newborns. Skin strips that are pressed on the skin to measure temperature are also not recommended for babies. Touching the skin of a baby can let the care provider know if the infant is warm or cool, but it cannot measure body temperature.

Another, newer method to measure temperature is called temporal artery thermometry, which measures the temperature of the blood flowing through the temporal artery on the forehead. This method is approved for newborns, infants, and toddlers under the age of 3 years. This method causes less discomfort than a rectal thermometer and is also considered very accurate. To take a baby’s temporal artery temperature, place the thermometer sensor in the middle of the baby’s forehead. Press and hold the scan button. Slowly move the thermometer across the baby’s forehead toward the top of the baby’s ear, making sure the sensor always touches the skin. Stop at the hairline and release the scan button. Remove the thermometer and read the temperature. If a baby’s temporal temperature is 100.4° F (38° C) or higher, parents should call the baby’s health-care provider (Johns Hopkins Medicine, 2019).

Educating Parents about Follow-up Care

When the infant is born and before discharge, they are given a complete physical examination by their health-care provider. The provider assesses the baby’s eyes, ears, mouth, skin, hips, legs, abdomen, heart, lungs, and genitalia. This exam is a precursor to nursery admission, eye prophylaxis, vaccinations, hearing tests, blood work, feedings, and eventual discharge. Newborn infants born vaginally are usually discharged after 48 hours but can leave as early as 12 to 24 hours with provider permission and from certain birthing facilities. For babies delivered by cesarean section, discharge does not usually happen until 72 hours after birth but may occur earlier.

The U.S. Department of Health and Human Services (2022a) strongly recommends that newborns see their health-care providers a minimum of 6 times before their first birthday, to have a complete assessment of physical and behavioral changes. The nurse should explain to parents the reasons for and the importance of these early health-care visits. The first year of life sees such tremendous periods of growth and change that regular visits are important.

The infant’s first visit with their provider outside the hospital should take place after they have been home for 2 to 3 days, making the newborn 3 to 5 days old (U.S. Department of Health and Human Services, 2022a). The health-care provider will assess weight, length, head circumference, signs of jaundice, number of wet and stooled diapers in a 24-hour period, and number of feedings in a 24-hour period. If the infant is formula-fed, they will ask how much formula the baby takes at each feeding and how often the baby is fed. If the infant is breast-feeding, they will want to know how often the baby is nursing and for how long on each side. They will probably ask about the latch to ensure that the baby is not suckling on the nipple alone but has a good deal of the areola in the mouth. The provider may ask to observe a feeding.

After that initial visit, the infant should be scheduled to see their provider at 1 month of age, 2 months of age, 4 months of age, 6 months of age, and 9 months of age (U.S. Department of Health and Human Services, 2022a). This equals the 6 visits before the first birthday. This is the minimum recommended number of visits in the first year of life. If parents or caregivers are worried or concerned about the baby’s health or if the baby shows any signs of illness, parents must be instructed not to wait until the next scheduled visit. They should call and see their provider right away.

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