NURSING CARE OF A FAMILY WITH A  After 1day of stable weight begins to gain

NEWBORN weight.
 The breastfed newborn recaptures birth
THE PROFILE OF A NEWBORN weight within 10 days; a formula-fed infant
accomplishes this gain within 7days.
 All infants begin to gain about 2 lb per
month (6 to 8 oz per week) for the first 6
months of life.

LENGTH

 The average birth length (50th percentile) of

a mature female newborn is 49 cm (19.2
in.).
 For mature males, the average birth length
is 50 cm (19.6 in.).
 The lower limit of expected birth length is
arbitrarily set at 46 cm (18 in.).
 Although rare, babies with lengths as great
as 57.5 cm (24 in.) have been reported.

HEAD CIRCUMFERENCE

 34 to 35 cm (13.5 to 14in.).
 A mature newborn with a head
VITAL STATISTICS circumference greater than 37 cm (14.8 in.)
 Vital statistics measured for a newborn or less than 33 cm (13.2 in.) should be
usually consist of the baby’s weight, length, carefully assessed for neurologic
and head and chest circumferences. involvement, although some well newborns
 Safety issues specific to newborn care have these measurements.
when taking these measurements, such as CHEST CIRCUMFERENCE
not leaving a newborn unattended on a bed
or scale and protecting against  Chest circumference is measured at the
hypothermia. level of the nipples. The chest
circumference in a term newborn is about 2
WEIGHT cm
 As long as newborns are breathing well,  (0.75 to 1in.) less than head circumference.
they are weighed nude and without a  32-33 cm
blanket soon after birth in the birthing room. VITAL SIGNS
 Initial weight for baseline data, an infant is
weighed nude once a day, at approximately TEMPERATURE
the same time every day, during a hospital
 99°F (37.2°C) at birth
or birthing center stay.
 The majority of heatloss occurs because of
 The birth weight of newborns varies
four separate mechanisms: convection,
depending on the racial, nutritional,
radiation, conduction, and evaporation
intrauterine, and genetic factors that were
 a newborn’s temperature stabilizes at
present during conception and pregnancy.
98.6°F (37°C) within 4 hours after birth.
 During the first few days after birth, a
newborn loses 5% to 10%of birth weight (6 TERMS:
to 10oz) (Thulier, 2016).
 Convection is the flow of heat from the
newborn’s body surface to cooler
surrounding air. Eliminating drafts, such as
from air conditioners, is an important way to
reduce convection heat loss.
 Radiation is the transfer of body heat to a NOTES:
cooler solid object not in contact with the
• they can only breathe through their
baby, such as a cold window or air noses; the only time newborns breathe
conditioner. Moving an infant as far from the through their mouths is when they are
cold surface as possible helps reduce this crying
type of heat loss.
 Conduction is the transfer of body heat to • unless their nasal passage has some
a cooler solid object in contact with a baby. blockage, which can lead to mouth
breathing; develop the reflex to breathe
For example, a baby placed on the cold
through their mouths at 3 or 4 months
base of a warming unit quickly loses heat to
the colder metal surface. Covering surfaces
BLOOD PRESSURE
with a warmed blanket or towel is necessary
to help minimize conduction heat loss.  newborn is approximately 80/46 mmHg at
 Evaporation is loss of heat through birth
conversion of a liquid to a vapor.  10th day, it rises to about 100/50 mmHg
Newborns are wet when born, so they can and remains at that level for the infant year
lose a great deal of heat as the amniotic  Blood pressure tends to increase with crying
fluid on their skin evaporates.  Hemodynamic monitoring is used when
continuous assessment is required.
PULSE

 Within 1hour after birth, as the newborn NOTES:

settles down to sleep, the heart rate • body produces a surge of hormones
stabilizes to an average of 120to 140 (cortisol) when you're in a stressful
beats/min. situation
 Slightly irregular Crying –180bpm
• temporarily increase your blood pressure
 Sleeping – 90-110 bpm
by causing your heart to beat faster and
 Femoral pulses can be palpated
your blood vessels to narrow.
 Best determined by listening to apical
heartbeat
PHYSIOLOGIC FUNCTIONS
RESPIRATION
A. CARDIOVASCULAR SYSTEM
 The first few minutes of life may be as high
as 90 breaths/min The peripheral circulation of a newborn remains
 over the next hour, this rate will settle to an sluggish for at least the first 24 hours, which can
average of 30 to 60breaths/min. cause cyanosis in the infant’s feet and hands
 Depth, rate and rhythm are likely irregular, (acrocyanosis) and for a newborn’s feet to feel cold
and short periods of apnea (Periodic to the touch.
respirations) is common and normal
NOTES:
 Watch newborns abdomen; primary
involves the use of diaphragm and • peripheral cyanosis around the mouth
abdominal muscles and the extremities (hands and feet)
 Newborns are obligate nose breathers and
• caused by benign vasomotor changes
show signs of distress if their nostrils
that result in peripheral vasoconstriction
become obstructed.
and increased tissue oxygen extraction
= resolved by warming the body
temperature
single best indicator of vitamin K–
dependent clotting factors).
 Assess for signs of bleeding in the infant,
such as black, tarry stools (different from
meconium stools, which have a greenish
Blood Values
shade), hematuria (blood in urine),
 Blood volume: 80 to 110ml/kg of body decreased hemoglobin and hematocrit
weight or about 300 ml total levels, and bleeding from any open wound
 Hemoglobin level: averages 17 to 18 g/100 or at the base of the cord. (These signs
ml of blood (the average for an adult is 11to would indicate more vitamin K is necessary
12g/ml) because bleeding control has not been
 Hematocrit is between 45% and 50% (for an achieved.)
adult, 36% to 45%). B. RESPIRATORY SYSTEM
 Red blood cell count is about 6 million  A first breath is a major undertaking
because it requires a tremendous amount of
cells/mm3 (for an adult, 3.5 to 5.5 million
pressure (about 40 to 70 cm H2O) for a
cells/mm3 ).
newborn to be able to inflate alveoli for the
 Indirect bilirubin level is between 1 and 4
first time.
mg/100 ml.
 The reflex to breathe is initiated by a
 High white blood cell count, about 15,000 to
combination of cold receptors (a lowered
30,000 cells/mm3 at birth (40,000 cells/mm3
partial pressure of oxygen (PO2 ), which
if the birth was stressful).
falls from 80 mmHg to as low as 15 mmHg
Blood Coagulation before a first breath) and an increased
partial carbon dioxide pressure (PCO2),
 It will take about 24 hours for flora to which rises as high as 70 mmHg before a
accumulate and for ongoing vitamin K to be first breath.
synthesized. This causes most newborns to C. GASTROINTESTINAL SYSTEM
be born with a lower than usual level of  Although the gastrointestinal tract is usually
vitamin K, leading to a prolonged sterile at birth, bacteria may be cultured
coagulation or prothrombin time. from the tract in most babies within 5 hours
 Vitamin K (AquaMEPHYTON) is usually after birth and from all babies at 24 hours of
administered intramuscularly into the lateral life.
anterior thigh, the preferred site for all  Newborn stomach holds about 60 to 90 ml
injections in newborns, immediately after  Newborn has limited ability to digest
birth (.5-1 mg IM 1st hour after birth) everything taken in, especially fat and
starch because the pancreatic enzymes,
lipase and amylase, remain deficient for the
Nursing Implications in giving Vitamin K: first few months of life.
 Give within an hour after birth.
 Administer IM injection into a large muscle,
Stools- usually passed within 24 hours after birth
such as the
 anterolateral muscle of a newborn’s thigh.  Meconium, a sticky,tar-like, blackish-green,
 Be certain to administer the injection at a odorless material formed from mucus,
time it doesn’t vernix, lanugo, hormones, and
 interrupt parent–child bonding or beginning carbohydrates that accumulated in the
breastfeeding. bowel during intrauterine life.
 If giving vitamin K for treatment, obtain
prothrombin time before administration (the
 2nd and 3rd day – changes in color and  Output: first 1or 2 days is about 30 to 60 ml
consistency (transitional stool: appear loose total Week1,total daily volume rises to about
and green) 300 ml.
 4th day (breastfed babies; pass three or E. IMMUNE SYSTEM
four light yellow stools per day that have a  Do not produce antibodies until 2 mos
soft consistency.  Born with passive antibodies
 newborn who receives formula usually (Immunoglobulin G) (Poliomyelitis, measles,
passes two or three bright yellow stools a diptheria, pertussis, chickenpox, rubella,
day of soft consistency. andtetanus)
 Newborn placed under phototherapy lights  Hepa B vaccine is administered before
as therapy for jaundice will have bright leaving the birth setting
green stools because of increased bilirubin
excretion.
 Newborns with bile duct obstruction have
clay-colored (gray) stools because bile
pigments cannot enter the intestinal tract.
 Blood-flecked stools usually indicate an anal
fissure.
 Newborn has swallowed some maternal
blood during birth and either vomits fresh
blood immediately after birth or passes a
black tarry stool after two or more days.
 If mucus is mixed with stool or the stool is
F. NEUROMUSCULAR SYSTEM
watery and loose, a milk allergy, lactose
 Neuromuscular function by moving their
intolerance, or some other condition
extremities, attempting to control head
interfering with digestion or absorption is
movement, exhibiting a strong cry, and
suspected.
demonstrating newborn reflexes.
NOTES:  Twitching or flailing movements of the
extremities in the absence of a stimulus
• Anal fissures are most commonly caused
because of the immaturity of the nervous
by damage to the lining of the anus
system; common and normal
or anal canal, the last part of the large
intestine

NEWBORN REFLEXES
D. URINARY SYSTEM 1. Blink Reflex
 Average newborn voids within 24 hours  Elicited by shining a strong light such as a
after birth flashlight into an eye.
 Newborns who do not void within this time 2. Rooting Reflex
need to be assessed for the possibility of  Cheek is brushed or stroked near the
urethral stenosis or absent kidneys ofureter corner of the mouth, the infant will turn the
 usually light colored and odorless head in that direction.
 6 weeks of age before much control over  This reflex serves to help a newborn find
reabsorption of fluid in tubules and food. Disappears at about the 3-4 months
concentration of urine becomes evident.
 Single voiding in a newborn is only about
15ml Specific gravity ranges from 1.008 to
1.010
NOTES:

• Absent BR: suggest significant

neurological problems
• Absent RR: Prematurity = develops at
28-30wks AOG

3. Sucking Reflex 7. Step (Walk)-in-Place Reflex

 When a newborn’s lips are touched, the  Newborns who are held in a vertical position
baby makes a sucking motion. with their feet touching a hard surface will
 This reflex also helps a newborn find food take a few quick, alternating steps
 Diminish at about 6 months of age.  Disappears by 3months
4. Swallowing Reflex
 The same as in the adult
 Food that reaches the posterior portion of
the tongue is automatically swallowed.
 Gag, cough, and sneeze reflexes also are
present in newborns to maintain a clear
airway.

NOTES:

• Absent SuR: Prematurity = develops at

32 wks AOG
• Absent SwR: Prematurity or Reflux

5. Extrusion Reflex
 Newborn extrudes any substance that is 8. Placing Reflex
placed on the anterior portion of the tongue  is elicited by touching the anterior lower leg
 Fades at 4months against a surface such as the edge of a
6. Palmar Grasp Reflex table.
 Newborns grasp an object placed in their  The newborn makes a few quick lifting leg
palm by quickly closing their fingers on it motions, as if to step onto the table.
 Disappears at about 6 weeks to 3 months
 After it fades, a baby begins to grasp
meaningfully

NOTES:

• The total absence of the stepping reflex

NOTES:
as well as it's continuance after 4 months
• disappearance of the extrusion reflex of age in babies could be due to motor
helps babies start to wean from the nerve injury, severe neurological deficit
breast or bottle, and learn to eat purees, during birth.
cereals, or softened table foods.
• Absence of the reflex at birth may
 Elicited with a loud noise or by jarring the
bassinet.
9. Plantar Grasp Reflex
 Most accurate method of eliciting the reflex
 When an object touches the sole of a
is to hold a newborn in a supine position
newborn’s foot at the base of the toes, the
and then allow the head to drop backward
toes grasp in the same manner as the
about 1in. In response to this sudden
fingers.
backward head movement, the newborn
 Disappears at about 8 to 9 months
first extends arms and legs, then swings the
 Preparation for walking.
arms into an embrace position and pulls up
the legs against the abdomen (Lehman &
Schor,2016).
 Strong for the first 8 weeks of life and then
fades by the end of the 4th or 5th month.

10. Tonic Neck Reflex

 When the arm and leg on the side toward
which the head is turned extend, and the
opposite arm and leg contract
 Also called a “boxer” or “fencing reflex.”
 Strong for the first 8 weeks of life and then NOTES:
fades by the end of the fourth or fifth month • can result from a birth injury, severe
asphyxia during the birthing process,
intracranial haemorrhage, infection, brain
malformation, and general muscular
weakness of any cause, and cerebral
palsy of the spastic type.

12. Babinski Reflex

 When the sole of a newborn’s foot is
stroked in an inverted “J” curve from the
heel upward, a newborn fans the toes
(positive Babinski sign)
NOTES:  Reflex remains positive (toes fan) until at
least 3 months of age
• The plantar grasp reflex is also of high
clinical significance, especially in terms
of the detection of spasticity. No reflex, or
a diminished one, during early infancy is
often a sensitive predictor of the
development of spastic CP
• Absent TNR: can be a sign of a
neurological problem

11. Moro Reflex (Startle Reflex) 13. Magnet Reflex

 If pressure is applied to the soles of the feet
of a newborn lying in a supine position, he
or she pushes back against the pressure.
 Test of spinal cord integrity (Crossed
extension reflex and Trunk Incurvation
Reflex)
16. Landau Reflex
 newborn is supported in a prone position by
a hand, the newborn should demonstrate
some muscle tone.

17. Deep Tendon Reflexes

 Both a patellar and a biceps reflex are intact
NOTES: in a newborn
• BR: test integrity of the corticospinal tract
(CST) eg: lesions

14. Crossed Extension Reflex

 When a newborn is lying supine, if one leg
is extended and the sole of that foot is
irritated by being rubbed with a sharp NOTES:
object, such as a thumbnail, the infant
raises the other leg and extends it as if • absence of the Landau may indicate a
trying to push away the hand irritating the sign of a neurological disorder, such as
first leg. cerebral palsy or motor neuron disease =
can cause posture, motor, and memory
issues later on

• DTR absent associated with low tone

and weakness is consistent with a lower
motor neuron disorder.

15. Trunk Incurvation Reflex

 A newborn lies in a prone position and is
touched along the paravertebral area on the
back by a probing finger, the newborn flexes
the trunk and swings the pelvis toward the
touch
THE PHYSIOLOGIC ADJUSTMENT TO
THE SENSES EXTRAUTERINE LIFE
Hearing

 Newborns appear to recognize their

mother’s voice almost immediately
 Respond with generalized activity to a
sound such as a bell
 Have difficulty locating where a sound is
coming from.

Vision

 Pupillary reflex or ability to contract the pupil

is present from birth
 Newborns demonstrate they can see by
blinking at a strong light (blink reflex) or by
following a bright light or toy a short
distance with their eyes as soon as they are
born (Clark-Gambelunghe & Clark,2015).
 Black and white; distance9-12 inches

Touch

 The sense of touch is also well developed at

birth
 Quiet down at a soothing touch, cry at
painful stimuli, and show sucking and
rooting reflexes that are elicited by touch.

Taste

 Has the ability to discriminate taste because ASSESSMENTS OF WELL-BEING

taste buds are developed and functioning APGAR SCORING
even before birth.
 baby continues to show a preference for  At 1minute and 5 minutes afterbirth
sweet over bitter tastes.  An assessment scale used as a standard
for newborn evaluation since 1958 (Apgar,
Smell Holaday, James,et al., 1958).
 Present in newborns as soon as the nose is
clear of lung and amniotic fluid.
THE PHYSICAL EXAMINATION
THE ASSESSMENT OF GESTATIONAL AGE
Newborns are said to be term if they are born
between 37 and 42 weeks of gestation or within 2
weeks of their due date.

THE HEALTH HISTORY

Important information to gather includes: THE APPEARANCE OF A NEWBORN

 Any complications of pregnancy such as The Skin

gestational diabetes, hypertension,
General inspection of a newborn’sskin includes
premature rupture of membranes, serious
color, any birthmarks, and general appearance.
falls, or other injuries
 Length of pregnancy and length of labor The Color
 Type of birth (vaginal or cesarean) and
Most term newborns have a ruddier complexion for
whether the infant breathed spontaneously
their first month
or needed assistance at birth
a) Cyanosis

b) Hyperbilirubinemia

c) Pallor

d) Harlequin Skin
NOTES:

• blood vessels that form incorrectly and

multiply more than they should = usually
harmless and tend to resolve on their
own

• begin to slowly disappear over time

(involution). By the time children reach
10 years of age, hemangiomas are
usually gone.
NOTES:
b) Mongolian spots
• having a healthy reddish colour

• Harlequin ichthyosis is caused  Collections of pigment cells (melanocytes)

by changes (mutations) in the ABCA12 that appear as slate gray patches across
gene, which gives instructions for making the sacrum or buttocks and possibly on the
a protein that is necessary for skin cells arms and legs of newborns.
to develop normally. It plays a key role in  They tend to occur most often in children of
the transport of fats (lipids) to most Asian, Southern European, or African
superficial layer of the skin (epidermis), ethnicity and disappear by school age
creating an effective skin barrier. without treatment (Smith & Grover, 2016).
 Be sure to educate parents that these are
• Harlequin ichthyosis is a severe genetic not bruises.
disorder that affects the skin. Infants with
this condition are born prematurely with NOTES:
very hard, thick skin covering most of
• 3-5yrs or persist to life
their bodies. The skin forms large,
diamond-shaped plates that are
separated by deep cracks (fissures)
Vernix Caseosa

noticeable on a term newborn’s skin, at least in the

Birthmarks skin folds, at birth.

Several common types of birthmarks occur in

newborns

a) Hemangiomas

NOTES:

• Vernix caseosa is a white, creamy,

naturally occurring biofilm covering the
skin of the fetus during the last trimester
of pregnancy.; produced in part by fetal
sebaceous glands around 17 weeks of
pregnancy.
Lanugo

 fine, downy hair that covers a term

newborn’s shoulders, back, upper arms,
and possibly also the forehead and ears.
 37-39 weeks – generous amount
 Post term – rarely have lanugo
 2 weeks usually disappear

Erythema Toxicum

 commonly presents on the skin of most term

newborns
 The rash usually appears in the first to
fourth day of life but may appear as late as
2 weeks of age.
Desquamation  It occurs sporadically and unpredictably and
may last hours or days.
 Within 24 hours after birth, the skin of most
newborns begins to dry
 Post term – extremely dry skin; leathery
appearance and there are actual cracks in
skin folds
 it helps to diagnose the newborn as post
term.

Skin turgor

newborn skin should feel resilient if the underlying

tissue is well hydrated.

THE HEAD
head usually appears disproportionately large
because it is about one fourth of the total body
length

Oher features include:

Milia

 At least one pinpoint white papule (a  The forehead appears large and prominent.
plugged or unopened sebaceous gland) is  The chin appears to be receding, and it
usually found on a cheek or across the quivers easily if the infant is startled or cries.
bridge of the nose of every newborn.  If a newborn has hair, the hair should look
 disappear by 3to 4 weeks of age full bodied; both poorly nourished and
 avoid scratching or squeezing the papule, preterm infants have thin, lifeless hair.
which could lead to secondary infection.  If internal fetal monitoring was used during
labor, a newborn may have a pinpoint ulcer
at the point where the monitor was
attached.
Fontanelles Molding

 Fontanelles are the spaces or openings After birth, this area appears prominent and
where the skull bones join asymmetric
 It is diamond-shaped and measures 2 to
3cm (0.8 to 1.2in.) in width and 3to 4 cm
(1.2to 1.6in.) in length.
 Posterior fontanelle is located at the junction
of the parietal bones and the occipital bone;
closes by the end of the second month.
 Anterior fontanelle can be felt as a soft spot;
normally closes at 12 to 18 months of age.

Caput Succedaneum

Sutures  is edema of the scalp that forms on the

presenting part of the head. It occurs in
 The skull sutures, the separating lines of the cephalic births and can either involve wide
skull, may override at birth because of the areas of the head or be so confined that
extreme pressure exerted on the head it’sthe size of a largeegg.
during passage through the birth canal.  No treatment is needed (Gooding&
 The overriding subsides in 24 to 48 hours McCLead, 2015).
THE EYES THE NECK
 Tears are rare; lacrimal ducts do not fully  newborn appears short with creased skin
mature until about 3 months of age. folds. head should rotate or turn freely on it.
 The iris will assume its permanent color  The neck of a newborn is not strong enough
between 3and 12 months of age. to support the total weight of the head but in
 should appear clear, without redness or a sitting position, a newborn should make a
purulent discharge. momentary effort at head control.
 Slight edema is often present around the  When lying prone, newborns can raise the
orbit or on the eyelids and remains for the head slightly, usually enough to lift the nose
first 2 or 3days out of mucus or spit-up milk
 cornea of each eye appears round and  Trachea usually appears prominent on the
proportionate in size to an adult eye front of the neck.
 The pupil, as in adults, should appear dark.  Thymus gland also appears enlarged
because of the rapid growth of glandular
THE EARS
tissue early in life
 newborn’s external ear is not as completely
THE CHEST
formed as it will be eventually, so the pinna
tends to bend forward easily.  Chest in most newborns looks small
 level of the top part of the external ear because the head is so large in proportion
should be even to a line drawn from the to it (an important finding at birth so the
inner canthus to the outer canthus of the largest diameter of the baby is born first).
eye and back across the side of the head  Both right and left sides should appear
 The AAP recommends all newborns be symmetric. Clavicles should appear straight
screened for hearing before discharge from and feel smooth
their birth setting (AAP, 2013).  A supernumerary nipple (usually found
 A hearing infant will blink, attend to the below and in line with the normal nipples)
bell’s sound, and possibly startle. may be present.
 both female and male infants, the breasts
THE NOSE
may be engorged because of the influence
newborn’s nose usually has milia present and tends of maternal hormones during pregnancy.
to appear large for the face.  RR: 30-60 b/m
 listening to lung sounds often reveals
rhonchi—the sound of air passing over
THE MOUTH mucus.

 newborn’s mouth should open evenly when THE ABDOMEN

he or she cries. The tongue may appear  The contour of a newborn abdomen looks
short or “tongue tied” because the frenulum slightly protuberant
membrane is attached close to the tip.  Bowel sounds show the bowel is beginning
 Inspect the palate of a newborn to be peristalsis and should be present within
certain it is intact. 1hour after birth.
 Well-circumscribed cysts (Epstein pearls)  On the right side, the edge of the liver is
can be seen on the palate from extra usually palpable 1 to 2 cm below the costal
calcium that was deposited in utero. Be sure margin.
to inform parents that these pearl-like cysts  On the left side, the edge of the spleen may
are insignificant, require no treatment, and be palpable 1to 2 cm below the left costal
will disappear spontaneously within a week. margin.
 Always inspect the cord clamp to be certain THE EXTREMITIES
it is secure; On day 6 to 10, it breaks free,
leaving a granulating area a few centimeters  The arms and legs of a newborn appear
wide that will heal during the following week. short in proportion to the trunk
 When a newborn voids, it demonstrates that  hands seem plump and are typically
there is at least one kidney functioning (but clenched.
not necessarily two).  fingernails feel soft and smooth and extend
 To finish an abdominal assessment, elicit an over the fingertips.
abdominal reflex. Stroking each quadrant of  When a newborn moves, the arms and legs
the abdomen with a finger should cause the should move symmetrically (unless the
umbilicus to move or “wink” in that direction. infant is demonstrating a tonic neck reflex).
 Newborn legs appear bowed and short.
THE ANOGENITAL AREA  Sole of the foot is flat because of an extra
pad of fat in the longitudinal arch.
Male Genitalia

 scrotum in most male newborns is

edematous and has rough rugae on the
surface.
 deeply pigmented indark-
 skinned newborns
 Both testes should be palpable in the
scrotum.
 Penis of newborns appears small,
approximately 2 cm long.
 The prepuce (foreskin) slides back very little
from the meatal opening

The Female Genitalia

 female newborns may appear swollen

because of the effect of maternal hormones
during intrauterine life.
 newborns also have a mucus vaginal
secretion, sometimes blood tinged
(pseudomenstruation)
 The discharge does not indicate an infection
or trauma and disappears in 1or 2days.

THE BACK
 normally assumes the position maintained
in utero for days after birth, with the back
rounded and arms and legs flexed across
the abdomen and chest.
 spine of a newborn typically appears flat in
the lumbar and sacral areas
 Inspect the base of a newborn’s spine
carefully to be certain there is no pinpoint
opening, dimpling, or sinus tract in the skin,
which suggest a dermal sinus or spina bifida
occulta