Newborn Assessment & Skills Ana H. Corona, DNP, FNP-BC Nursing Instructor Revised September 2013 Bates’ Pocket Guide to Physical Examination and History Taking, 2008; Foundations of Nursing, Duncan & White, 2010.

Normal Newborn: General Appearance Well-flexed, full range of motion spontaneous movement Common variations Legs extended with frank breech Signs of potential distress or deviations from expected findings Posture limp Asymmetry of movement Persistent tremor, twitching

Vital Signs Temperature - range 36.5 to 37 axillary (97.7-98.6) Common variations Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery Signs of potential distress or deviations from expected findings Temperature is not reliable indicator of infection A temperature less than 36.5

Heart Rate Heart rate - range 120 to 160 beats per minute Common variations Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying Signs of potential distress or deviations from expected findings Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound

Respirations Respiration - range 30 to 60 breaths per minute Common variations Bilateral bronchial breath sounds Moist breath sounds may be present shortly after birth Signs of potential distress or deviations from expected findings Asymmetrical chest movements Apnea >15 seconds Diminished breath sounds Seesaw respirations Grunting Nasal flaring Retractions Deep sighing Tachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor

Blood Pressure Blood pressure - not done routinely Factors to consider Varies with change in activity level Appropriate cuff size important for accurate reading Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities Sign of potential distress or deviations from expected findings Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta

General Measurements Head circumference - 33 to 35 cm Expected findings Head should be 2 to 3 cms larger than the chest Chest circumference - 30.5 to 33 cm Common variations Molding of head may result in a lower head circumference measurement Head and chest circumference may be equal for the first 24 to 48 hours of life Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.) Length range - 48 to 53 cms (19 - 21 inches)

Skin Expected findings Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals vernix caceosa Lanugo (baby hair) Turgor good with quick recoil Hair silky and soft with individual strands Nipples present and in expected locations Cord with one vein and two arteries Cord clamp tight and cord drying Nails to end of fingers and often extend slightly beyond

Common Variations Acrocyanosis - result of sluggish peripheral circulation Mongolian Spots: Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent. Not malignant. Resolves in time. Mottling: Generalized red and white discoloration of skin of chilled infants with fair complexion. Physiologic Jaundice: Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn. Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days. Unconjugated bilirubin circulating in the blood stream that is deposited in the skin. Skin color may range from yellow to orange to greenish hues.

Common variations Milia: Tiny white papules (plugged sebaceous glands) located over nose, cheek, and chin. Erythema toxicum: Most common newborn rash. Variable, irregular macular patches. Lasts a few days Petechiae: Pinpoint, flat hemorrhages often visualized on head, face, and chest. Associated with rapid onset of pressure followed by immediate release of pressure during birthing process. Skin tags usually around ears or digits (tied off) Harlequin Coloring: The color of the newborn's body appears to be half red and half pale. This condition is transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system.

Signs of potential distress or deviations from normal findings Jaundice within 24 hours of birth General cyanosis Circumoral cyanosis between feedings Petechiae or ecchymoses other than on presenting part All rashes with exception of erythema toxicum Pigmented nevi Yellow vernix Hemangioma Pallor Forceps marks

The Head Expected findings Common Variations Anterior fontanel diamond shaped 2-3 - 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat Common Variations Caput succedaneum: Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses suture line and decreases rapidly in a few days after birth. Molding of fontanels and suture spaces

Signs of potential distress or deviations from normal findings Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalohematoma Closed sutures

The Eyes Expected findings Slate gray or blue eye color No tears Fixation at times - with ability to follow objects to midline Red reflex Blink reflex Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light

Common Variations Edematous eyelids Uncoordinated movements May focus for a few seconds

Signs of potential distress or deviations from expected findings Discharges Chemical conjunctivitis Opaque lenses Absence of Red Reflex Epicanthal folds in newborns not of Oriental descent Doll’s Eyes beyond 10 days of age-----Doll's Eyes Reflex: When the head is moved slowly to the right or left, the eyes do not follow nor adjust immediately to the position of the head. This reflex should not be elicited once fixation is present. The persistence of the Doll's Eyes Reflex suggests neurologic damage. Reflexes absent Subconjunctival hemorrhage

Ears: Expected Findings Pinna top on horizontal line with outer canthus of eye Loud noise elicits Startle Reflex Flexible pinna with cartilage present Common Variations Skin tags on or around ears

Signs of potential distress or deviations from expected findings Ear placement low Preauricular sinus Clefts present Malformations Cartilage absent

The Nose Look for flaring of the alae nasi as a sign of increased respiratory effort. Look for hyper- or hypo-telorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers). A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected.

The Palate and Mouth Check for cleft lip and palate Observe the size and shape of the mouth. Microstomia - seen in Trisomy 18 and 21. Macrostomia - seen in mucopolysaccharidoses. Fish mouth - seen in fetal alcohol syndrome. Epstein pearls - small white cysts that contain keratin, frequently found on either side of the median raphe of the palate. Ranulas - small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts.

The Tongue, Teeth and Chin Macroglossia - Hypothyroidism, mucopolysaccharidoses Teeth Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached. Chin Micrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins syndrome, Hallerman Streiff syndrome.

The Neck Palpate over all muscles, palpate clavicles for possible fractures. Web neck found in Turner's and Noonan's syndromes. Torticollis usually secondary to sternocleidomastoid hematoma. Cystic hygromas most common neck mass. Lymph nodes are unusual at birth and their presence usually indicates congenital infection.

Chest and Lungs Observe respiratory rate, respiratory pattern (periodic breathing, periods of true apnea). Observe chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there may be some enlargement of the breasts secondary to maternal hormones.

The Chest Expected findings Evident xiphoid process Equal anteroposterior and lateral diameter Bilateral synchronous chest movement Symmetrical nipples Common variations "Witch's milk“ Enlarged breasts Accessory nipples

Signs of potential distress or deviations from expected findings Asymmetrical chest movements Sternum depressed Marked retractions Absent breast tissue Flattened chest Supernumerary nipples Nipples widely spaced Bowel sounds auscultated

Cardiovascular System Measure heart rate, blood pressure in upper and lower extremities, respiratory rate. Inspection Check baby's color for pallor, cyanosis, and plethora. Palpation Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready). Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, situs inversus, or other thoracic problem. Auscultation Note rhythm and presence of murmurs that may be pathologic.

Patent Ductus Arteriosis Before birth, there is a natural opening between the aorta (the main artery to the body) and the pulmonary artery (the main artery to the lungs) called the ductus arteriosus. This opening usually closes shortly after birth. PDA occurs when this opening fails to close; PDA occurs in about 10% of infants. PDA is often treated initially with a medication called indomethacin. If the ductus fails to close on its own or with indomethacin, surgery is performed. A small incision is made on the left side of the chest. The ductus is either ligated (tied off) or cut.

Atrial Septal Defect ASD is a congenital heart defect. In fetal circulation there is normally an opening between the two atria (the upper chambers of the heart) to allow blood to bypass the lungs. This opening usually closes about the time the baby is born. If the ASD is persistent, blood continues to flow from the left to the right atria. This is called a shunt.

Ventricular Septal Defect Before a baby is born, the right and left ventricles of its heart are not separate. As the fetus grows, a muscular wall forms to separate these lower heart chambers. If the wall does not completely form, a hole remains. This is what is known as VSD. It is estimated that up to 1% of babies are born with this condition. In the vast majority (80-90%) of babies born with this condition, the hole is small. They will have no symptoms, and the hole will close spontaneously as the muscular wall continues to grow after birth. If the hole is large, then too much blood will be pumped to the lungs, leading to congestive heart failure. These babies are often have symptoms related to the problem and may need medicine or surgery to close the hole.

The Abdomen Expected findings Dome-shaped abdomen Abdominal respirations Soft to palpation Well formed umbilical cord Three vessels in cord Cord dry at base Liver papable 2 - 3 cms below right costal margin Bilaterally equal femoral pulses Bowel sounds auscultated within two hours of birth Voiding within 24 hours of birth Meconium within 24 - 48 hours of birth Common variations Small umbilical hernia

Signs of potential distress or deviations from expected findings Bowel sounds absent Peristaltic waves visible Abdominal distention Palpable masses Scaphoid-shaped abdomen Omphalocele Base of cord with redness or drainage Cord with two vessels

The Abdomen Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or abnormalities in abdominal musculature. Note abdominal distension. Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not.

The Abdomen Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis. After locating these organs (checking for situs inversus), palpate for any abnormal masses. Auscultate for bowel sounds. Examine for hernias - umbilical or inguinal. Inspect anal area for patency and/or presence of fistulas.

Genitourinary Kidneys Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term newborn. The technique for palpation is either a) one hand with four fingers under the baby's back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney).

Expected Findings Common Variations Edematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia Common Variations Hymenal tag Pseudomenstruation Smegma Increased pigmentation Ecchymosis and edema after breech birth "Red brick" pink-stained urine due to uric acid crystals

Signs of potential distress or deviations from expected findings Labia fused Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia

Signs of potential distress or deviations from expected findings Male Genitalia Expected Findings Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voiding Common variations Prepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech delivery Signs of potential distress or deviations from expected findings Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia

Male Genitalia Term normal penis is 3.6 + 0.7 cm stretched length. Inspect glans, urethral opening, prepuce and shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias. Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes

Female Genitalia Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally. 

Extremities and Skeletal System Spine Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles. Upper extremity Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers. Lower extremity See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.

Extremities Expected findings Maintains posture of flexion Equal and bilateral movement and tone Full range of motion all joints Ten fingers and ten toes Legs appear bowed Feet appear flat Palmar creases present Sole creases present Negative hip click Grasp reflex present

Signs of potential distress or deviations from expected findings Asymmetrical movement of extremities Polydactyly Unequal tone Syndactyly Unequal leg length Asymmetrical skin creases posterior thigh Dislocation of hip Simean crease Persistent cyanosis of nail beds Marked metatarus varus

Back and Rectum Expected findings Intact spine without masses or openings Trunk incurvature reflex Patent anal opening "Wink reflex" present Signs of potential distress or deviations from expected findings Limitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cyst

Neuromuscular System Expected findings Maintains position of flexion When prone, turns head side to side Holds head and back in horizontal plane when held prone Ability to hold head momentarily erect Signs of potential distress or deviations from expected findings Hypotonia Quivering Limp extremities or straightening of extremities Clonic jerking Paralysis