What is the nurse’s initial action while caring for an infant with a slightly decreased temperature?

A full newborn nursing assessment should include measurements such as weight, length, head circumference, and vital signs. The assessment should start by generalizing the infant’s appearance, including position, movement, color, and breathing (Overview, 2020). During this general observation, the RN should identify any apparent deformities, how the baby moves, their color while resting, and their respiratory effort (nasal flaring, grunting, retractions in the chest).

The skin should be assessed for abnormalities such as areas of abnormal pigmentation, congenital nevi, macular stains, or hemangiomas. Vesicles, bullae, and pustules in the newborn may be caused by infections, congenital disorders, or other diseases (Reginatto et al., 2017). Milia are white papules that resolve within a few weeks. These are the most common problem with the skin and are harmless.

The head should be assessed next and looked for symmetry. The fontanelles should be soft and flat. The sutures of the skull should be felt. There may be molding from the birth canal, but if this lasts longer than 2 to 3 days after birth, there may be a problem. Caput succedaneum is an area of edema on the head. This area may be present at birth, crosses suture lines, and resolves within a few days. Cephalohematomas are collections of blood that are present in 1 to 2 percent of newborns. On palpation, they form a fluctuant mass that does not cross suture lines, which may increase in size after birth, and usually take weeks to months to resolve. Subgaleal hemorrhages are blood collections between the aponeurosis covering the scalp and the periosteum. Subgaleal hemorrhages extend across suture lines but feel firm and fluctuant. Blood loss from these hemorrhages can be life-threatening and should be evaluated immediately (UpToDate, 2019). The face should be assessed for symmetry. The eyes should also be assessed for symmetry, spacing, and movement. The ears should be assessed for symmetry and to ensure they are parallel to the eyes and not a common set, indicating a problem. The nose should be assessed for patency. The mouth should be examined for any cleft or abnormality. This examination includes palpation of the palette. A small jaw could also indicate a problem. The neck is palpated for masses, and the clavicles are palpated for crepitus, which could indicate an injury.

The chest should be examined for size, shape, and symmetry. A malformed chest could indicate a problem. Retractions may be observed with respiratory difficulty. Breast size and location should be assessed. The lungs should be auscultated while the infant is quiet. Respirations should be observed and counted for a full minute. Heart rate should be assessed with a stethoscope while listening for murmurs. The femoral pulse should also be palpated.

The abdomen should be assessed for shape. Any abnormal distention should be reported to the provider, as this could indicate a problem with the infant. The umbilical cord is evaluated to ensure it is clean without any signs of infection, such as redness or discharge.

The genitalia should also be observed. The size and location of the labia, clitoris, meatus, and vaginal opening should be assessed in the female infant. The labia minora and clitoris are prominent in preterm infants, while the labia majora becomes larger as the infant approaches the term. A male infant should evaluate the presence of testes, size of the penis, appearance of the scrotum, and the position of the urethral opening. A newborn who has had a circumcision should be assessed for excessive bleeding or signs of infection. One or both undescended testicles should be reported to a provider. A male urethra with the abnormal ventral placement of the urethral opening is hypospadias. A newborn with hypospadias should not have circumcision and should see a urologist. The anus is examined for patency. Imperforate anus is not always visible. A baby who has not passed meconium and has a distended abdomen needs urgent evaluation by a provider. A small sacral dimple may be normal, but a larger dimple needs evaluation.

The extremities should be assessed for proper movement and to ensure there are 5 fingers on each hand and 5 toes on each foot. The hips should be evaluated. The Ortolani and Barlow maneuvers use adduction and posterior pressure to feel for dislocation and abduction and elevation to feel for reduction.

Newborn pain should be assessed every time the newborn gets vital signs and during a painful procedure, such as circumcision, according to hospital policy. This pain should be evaluated using a validated tool. There are many options available (Assessment, 2019).

Humans are homotherms; capable of maintaining body temperature at a relatively constant level despite changes in the external environment. The ability of infants to regulate temperature in response to thermal stress is limited. Infants are unable to sweat in order to give off excessive heat when they become overheated.

The infant is capable of heat production through three mechanisms 1) voluntary muscle activity, 2) involuntary muscle activity, and 3) metabolism. Voluntary and involuntary muscle activity is limited and requires a chemical reaction utilizing large stores of energy. Term infants are capable of assuming a flexed position when cool and an extended position when overheated. The ability is limited in the premature infant, though it may be present to some extent.

Non-shivering thermo genesis appears to be the most consistent method of heat production in the neonate regardless of gestational age or birth weight. The major source of heat energy in the newborn is fatty acids. Thermo genesis is directly dependent on tissue oxygenation to utilize heat energy. Oxidized fatty acids generally are believed to derive from brown fat stores in the neonate.

Brown fat has high vascularization and is virtually nonexistent in preterm infants. Term infants have approximately 16 percent of body tissue mass as adipose tissue, but the preterm infant may have as little as 3.5 percent adipose tissue per body weight. Brown fat is located around the mediastinal structures, kidneys, scapulas, axilla and nape of the neck. Primitive brown cells first appear at 26-30 weeks gestation and ordinarily disappear by three to five weeks after birth.

Upon exposure to cold, thermal receptors in the skin (many of which are located in the face) signal the neonate’s central hypothalamus resulting in sympathetic nervous system arousal and the release of norepinephrine. The release of norepinephrine then stimulates the hydrolysis or breakdown of the brown fat. The rapid metabolism of brown fat produces heat, which warms the blood perfusing surrounding tissue. This heat is then transferred via the circulation to the rest of the body. This process consumes a lot of oxygen and glucose.

Asphyxia and hypoxia further compromise the infant’s ability to generate heat. Utilizing energy to produce heat requires an increase in oxygen consumption. In the hypoxic state, two molecules of adenosine triphosphate (ATP) are generated from a molecule of glucose instead of 38 molecules of ATP generated in the normally oxygenated infant. In order to produce heat energy in the hypoxic state, greater glucose stores must be utilized. Without sufficient oxygenation, asphyxiated or hypoxic infants have a decreased ability to generate heat. When the infant with already limited resources for heat production encounters environmental changes that threaten his ability to maintain an adequate temperature, a serious condition exists.

The metabolic rate gradually increases during the first week of life. Heat production also improves during the first few days of life with the institution of feedings. It is not clear why heat is produced. It may be due to increased metabolism during digestion, or it may be that heat can be generated when sufficient energy is provided via ingestion. Ingestion of human milk has been found to increase metabolism in low birth weight infants, leading to production of heat. Thermoregulatory needs gradually change as the infant grows, matures and feeds.