Maternity - Newborn, part 8: Circumcision, Bathing and Cord Care, Crib Safety, Safe Sleep, Car Seat Safety
by Meris Shuwarger BSN, RN, CEN, TCRN November 27, 2021 Updated: June 16, 2022 10 min read
Hi, I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about some important discharge teaching for the caregivers of a newborn. I'm going to be following along using our maternity flashcards. These are available on our website, leveluprn.com, if you want to grab a set for yourself, and if you already have a set, I would invite you to follow along with me. Let's go ahead and get started. So, first up, we're talking about circumcision, which is the removal of the foreskin from the penis of, in this case, an infant. And in the United States, circumcision is fairly common. This is just about the important teaching related to circumcision. This is not talking about the whether or not an infant should be circumcised or should not be circumcised. This is not about the morality of that decision. This is just the important patient teaching for you to provide to your patients should they make the decision for themselves and for their families that this is a procedure they would like to have done.
So in this instance, really, there's only one major contraindication to circumcision, and that would be if the child has hypospadias or epispadias, meaning that the urethra typically is at the center of the tip of the penis. However, in hypospadias, it actually is occurring on the inferior side there of the penis. That's where the urethral opening is. Or with epispadias, it is happening on the superior side of the penis. The reason that circumcision is contraindicated is actually because the foreskin can be used for repair of this hypo or epispadias in the future. So we would not want to circumcise this infant and lose that tissue that could be used for surgical repair. Now, when it comes to nursing care, the biggest thing is going to be pain relief measures. So this might be sucrose is sometimes applied to a pacifier to-- which has sort of an analgesic effect on the infant. Also, just providing a pacifier can help, and then giving the baby acetaminophen and encouraging cuddling with the caregivers as well can help to decrease pain.
Now, when it comes to parental teaching, there's a lot that the parents need to know to take care of this infant following a circumcision. So a big one is, has the baby urinated within six to eight hours following the procedure? We need to know about that. If not, we could be at risk for urinary retention and obstruction here, which is a big problem. So we need to know about the urination of the infant following that. The penis itself should be cleaned with warm water at every diaper change. And then, if the child had the Gomco clamp procedure, we would want them to apply petroleum jelly to the penis at every diaper change as well. And typically, we would just give them a tube of petroleum jelly and teach them just to squirt a liberal amount on the head of the penis prior to putting the new diaper all the way back on.
If there is a yellowish crust forming at the circumcision site, that is normal. That is a normal part of the healing process, and we would want to teach the caregivers not to remove that yellowish crust, that this is a good and normal part of healing. And then we also don't want to give a tub bath until the circumcision site has completely healed because that can lead to an increased risk of infection and delayed healing as well. As with any sort of surgical procedure, we should be monitoring for signs of infection as well, so redness, swelling, fever, foul drainage. Anything like that should be reported to the provider. Now, moving on and talking about bathing and cord care, umbilical cord care. So, bathing, you'll see we have a lot of bold red text here on this card, which means that we thought it was pretty important for you to pay attention to. One of these is that the water heater temperature should be set to less than or equal to 120 degrees. Any more than that and we are risking burns to this infant.
Now, when it comes to actually washing the infant, we want to go from cleanest to dirtiest, so we're going to wash the face first, typically starting with the eyes, right? We don't think of these as being very dirty. We would do one side of a washcloth and then a different part of the washcloth on the other eye, inside to out, and then wash the rest of the face. But the genitals should be washed less because, in theory, that's the dirtiest part of the infant because that's where they're passing stool and urine from, right, is going to be in that perineal area, so we want to wash that last. We do need to clean in between those skin folds. Remember, infants get real dirty when they get to the phase where they're clenching their hands all the time. I remember my daughter, she just smelled so bad, and I was like, "What is the deal? I just gave you a bath this morning." And I realized that, because she's clenching her little fists so tight, she just had all this like crusty stuff inside her palms, and I had to unfold her palms and really get in there and scrub, so those skin folds can be really gross. And think about also the skin folds in the diaper area are going to be exposed to a lot of heat, moisture, and then things like urine and stool.
We want to complete a bath two to three times a week with mild soap. Infants do not need daily cleaning with soap, and in fact, doing so can lead to problems and dry out their skin, so only two to three times a week. Keep baby warm during bath and dry them thoroughly after. Again, they don't regulate their temperature well, so we need to help them with that. And we don't immerse the infant in water until after their umbilical cord has fallen off. After that stump has fallen off, then they can be immersed in water during bath time. I mean, responsibly, but we don't want to cover up that stump at any point in time with water. So when it comes to how do we actually care for the umbilical cord then, well, the reason we don't want to immerse them in water is because we want to keep that cord stump dry. We can give them sponge baths until that stump falls off, which is usually about 10 to 14 days after birth, and then we also want to avoid undue pressure on that stump. So when we are putting a diaper on, we're actually going to fold the top of the diaper at the front down so that it's underneath the umbilical cord. We would not want to put it over top of the cord because that could lead to friction. It's trapping moisture and heat and exposing to bacteria. We don't want any of those things. And then, of course, monitor for infection. Are we seeing redness, swelling, drainage, anything like that coming from the cord? That's a big deal. We need to tell the provider.
Now, crib safety and sleeping, this stuff, I mean, everything on this card should be bold and red because it's so important to talk about safe sleep in the newborn. So crib safety contributes to safe sleep. So firm, tight-fitting mattress, covered only by a fitted sheet. So tight-fitting mattress means that the mattress fits tightly inside the crib. It's not small and kind of wiggles around, right? It needs to be a firm mattress, and we also want a tight fitted sheet over the mattress. We don't have anything else in that crib. The crib slats should be less than or equal to two-and-three-eighths inches or six centimeters apart. So we want them to be close together, right? We don't have anything in the crib except for the mattress and the fitted sheet and the baby. So we're not putting toys in there. We're not putting blankets. There's no pillows. We don't have crib bumpers in there. Anything that goes into the crib, aside from the mattress, fitted sheet, and the infant should not be there. And then we want to make sure that the crib is kept away from windows, cords, and blinds. So if there's a chance that the cord for the blinds could be in the crib because it's long, we don't want that. That's a choking hazard that could cause harm to the child. And then we want it to be away from windows and vents and things like that because remember, again, infants have a hard time with thermo-regulation, so we don't want to have that heat loss through radiation, being close to a window, or through convection, being close to a vent.
Now, when it comes to safe sleep. We put the infant on their back to sleep. I remember being a kid and seeing this big campaign called Back To Sleep because, when I was an infant, the teaching was you put us on our tummies to sleep. So Back To Sleep is the guidance and that, actually, it may sound counterintuitive, but it helps to prevent accidental choking with reflux. Prevent overheating during sleep, so dress the infant appropriately. Infants actually don't need to be bundled up as much as you might think. We do want them to be covered, but we can put them in a light sleep sack or something along those lines. But we don't want to put the infant in fleece footie pajamas with a heavy sleep sack in July. Overheating is really bad for the infant, so avoid overheating. Teach parents that infants sleep for 14 to 17 hours a day. It is not in one continuous block, though, so it is normal for them to sleep frequently throughout the day and have these short periods of sleep, but they're frequent. And then we want to encourage room sharing, meaning the crib and the parents' bed are in the same room. Room sharing for up to a year is shown to decrease the incidence of SIDS, sudden infant death syndrome, but we don't want to bed-share. Bed-sharing or co-sleeping can increase the risk of SIDS for many, many reasons. But again, remember firm mattress, a crib mattress, that's what they should be sleeping on, not an adult mattress, which is squishy and that sort of thing, not with another person in the bed, or blankets, things along those lines. So that is safe sleep. And we do have our cool chicken here, which is about the ABCs of safe sleep. This is very commonly taught: alone, on their backs, and in a crib.
Lastly, and this is the last card in the newborn care section, we are talking about car seat safety. Now, I want to preface this by saying that the rules and regulations of car seat safety change over time. And additionally, a lot of these things have to do with what the bare minimum is as required by a state. So, for instance, when my daughter was born, the bare minimum requirement was that she had to be kept rear-facing up until age one. Now, the law is up until age two. However, we kept my daughter rear-facing until the age of four based on evidence-based practice. My son is three years old. He is still rear-facing. So I just want you to understand that this has to do with the minimums, the bare minimums, or the state laws, things like that, not necessarily always keeping up with the evidence-based practice that is out there. So placing the car seat should be in the back seat in the middle seat, meaning not on the right or the left of the back seat, but in that middle seat, because that is going to best protect an infant from side impact. We want to use a rear-facing seat with a five-point harness for an infant. Rear-facing is going to protect those bones and joints from impact better than forward-facing, where I keep moving forward because of inertia and my neck keeps moving forward, right, things like that. Rear-facing, if the car stops and the passengers keep moving forward, I'm being cradled in my back. It's actually helping to protect my still-immature bones and joints.
The car seat should be installed at a 45-degree angle. We want to position the straps for a rear-facing seat at or below the level of a child's shoulders. Forward-facing, it actually should be from above their shoulders. But for rear-facing, for infants, the straps of the car seat should come from the level of their shoulders or even from slightly below the level of their shoulders. This is for all car seats with five-point harnesses. There is a chest clip, and as the name may imply, it should be at the level of the chest, not at the abdomen. So the chest clip should be at the child's nipple level or armpit level because the chest clip should be coming at the sternum. That is going to protect me, right, better there. If the chest clip is on the abdomen, all of my organs are under there, and pressure is going to be applied to my abdomen and to my organs. That is not good. And then keep the infant rear-facing for a minimum of two years. However, I would encourage you to look at the evidence-based practice and make decisions for your family based on how long you would like to rear-face, based on new evidence that is coming out. So, remember, we're talking about bare minimum state laws.
I hope that review was helpful for you. I'm going to ask you some questions, some quiz questions, so you can test your knowledge of some key facts I provided you. Okay, so first up, I want you to think about caring for a family unit, and the parent of a circumcised newborn says to the nurse, "Hey, I see this yellow crust on my child's penis. What do I do?" How should the nurse respond? What would be something that you would say to this parent when they ask about that? Next up, at what point is it okay to immerse a baby in water during a bath? At what point can they be immersed in water? Next, I want you to tell me, what are the ABCs of safe sleep? Tell me what A, B, and C stand for. And last but certainly not least, where should the chest clip of a car seat be positioned on a child? Give me the specific anatomical location. Let me know how you did in the comments. I can't wait to hear. Thanks so much, and happy studying.
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