1. Preparing for OB Clinicals: Newborn Physical Assessment

2. Remember…..
always be organized in your neonatal assessments. Start with the infant’s head and work your way down in an systematic manner. This will help you remember all the components of the assessment

3. Vital Signs Pulse Respirations Axillary Temperature**
bpm. Listen for a full minute. Assess rate and rhythm. Extra sounds?
Respirations
30-60 bpm. Again, listen for a full minute. Expect brief periods of apnea along with periods of fast/slow breathing. This is normal. Neonates are abdominal breathers
Axillary Temperature**
F or C
If the baby is too warm, open blanket, remove hat and recheck temp. in minutes. If the baby is cold, double wrap, apply hat and recheck in minutes. Be sure to notify your nurse if these measures do not normalize the infant’s temperature

4. Activity Active Irritable Lethargic Quiet Sleeping
Crying should not be high-pitched
Could indicate increased ICP or drug withdrawal
Should quiet easily
Lethargic
Hypoglycemic?
Quiet
Sleeping

5. Sutures and Fontanels

6. Head Shape Size Fontanels Sutures Caput Cephalahematoma
Molding present?
Size
Usually 1-2 cm larger than chest
Fontanels
“Soft spots”
Anterior diamond-shaped. Posterior triangular shape
Bulging indicates increased cranial pressure
Sunken fontanels indicate dehydration
Sutures
Space between cranial bones. Overlapping of skull bones? Benign finding
Caput
Soft tissue injury at birth. Edematous. Resolves quickly; within 1-2 days
Cephalahematoma
Birth trauma. Blood pocket between skull and periosteum. Places the infant at greater risk of developing jaundice. Takes several weeks to resolve

7. Caput and Molding Cephalhematoma

8. Caput vs. Cephalhematoma

9. Notice the pitting edema
Caput Succedaneum

10. Eyes Placement Drainage Sclera Muscular Control
Abnormal placement could indicate chromosomal problems
Drainage
Infection?
Reaction to erythromycin?
Sclera
Yellow? Think jaundice
Hemorrhage? Birth trauma
Muscular Control
Strabismus (cross-eyed) is a normal finding due to weak eye muscles. Resolves spontaneously

11. Strabismus

12. Scleral Hemorrhage

13. Nose Drainage? Patent Bilateral Nares? Nasal Flaring? Sneezing?
Indicates respiratory difficulty
Sneezing?
Normal finding. Clears the nostrils of amniotic fluid and/or mucus. Reassure parents

14. Ears Placement Size Hearing Acuity
Low set ears could indicate chromosomal abnormality
Size
Hearing Acuity
Hearing screens done in most US hospitals. Any abnormalities followed up promptly; referred to specialist

15. Ear Placement
Normal-set ears
Low-set ears

16. Assessing the Mouth Mucous Membranes Hard/soft Palate Tongue
-Pink, moist
Hard/soft Palate
-Intact. Assess with a gloved finger
Tongue
-Not enlarged/protruding (Down Syndrome?)
-Thrush? White plaque on tongue/cheeks?
Short Frenulum (tongue-tied)
-May impede breastfeeding success. May be
clipped by pediatrician
Assess Suck
-Use a gloved baby finger. Stroke the roof of the
mouth to initiate the reflex
Epstein’s Pearls
-Benign white spots on gum line

17. Epstein’s Pearls

18. Short Frenulum (Tongue-Tied)

19. Thrush

20. Assessing Hydration Status
Adequate Hydration
Moist mucous membranes
No cracked/chapped lips
Adequate urinary output
No “rust stains” on diaper
These are uric acid crystals which confirms a degree of dehydration
No sunken fontanels
Not jittery
Hypoglycemic?

21. Assessing for Hypoglycemia
Risk Factors for Newborn Hypoglycemia:
Infant of a diabetic mother (IDM)
Poor breastfeeding; prolonged periods between feedings
LGA: Large for gestational age (more than 9 lbs or 4,000 grams)
SGA: Small for gestational age (less than 5 lbs or 2,500 grams)
Premature infant
Septic
**Blood glucose levels must be monitored closely to ensure at-risk babies are identified and treated. Usually feeding formula X 1 (20 mL) will resolve the hypoglycemia. It is essential to re-check the infant’s blood glucose level minutes after the formula is provided to ensure the nursing intervention was effective

22. Neck/Clavicles Movement Tone Assess for Nerve Damage
In upper arms
Erb-Duchenne paralysis (Erb’s Palsy)
Fractured Clavicle
Decreased movement/tone in one arm
Crepitus
Run fingers along
both clavicles simultaneously
to assess for fractures

23. Skin Color Bruising Mongolian Spot Newborn Rash (erythema toxicum)
Pink, ruddy, mottled, cyanosis, pallor, jaundiced, acrocyanosis
Bruising
At risk for jaundice (r/t biliburin)
Mongolian Spot
Normal finding. Document to prevent charges of abuse!
Newborn Rash (erythema toxicum)
Vernix Caseosa
White, cheezy/waxy substance. Disappears by term
Lanugo
Fine, downy hair. Disappears by term
Milia (tiny white pimples)
Blocked sebaceous glands. Benign

24. Vernix

25. Lanugo

26. Nevi Simplex or “Stork Bites”

27. Milia

28. Erythema Toxicum (Newborn Rash)

29. Acrocyanosis
Hands and feet remain appear blue/cyanotic. Normal for hours after birth. Why? Perfusion goes to main organs; then to the periphery.

30. Diaper Rash

31. Mongolian Spot

32. Jaundice Assessment
Use your thumb and apply gentle pressure on a bone to blanch the skin
Remove your thumb. If thumb print is white, no jaundice
If thumb print is yellow, jaundice is present
Jaundice starts at the head and works down the body
Start at the forehead, then nose, chin, sternum and finally the knees
Document: “Jaundiced to the level of the…..” The lower it is, the more serious the problem
Sclera, palms, and mucus membranes will also appear yellow

33. Chest/Respiratory Shape Respiratory Movements Adventitious Lung Sounds
Barrel-shaped chest
Respiratory Movements
Bilateral movement; no “see-saw” breathing
Adventitious Lung Sounds
Crackles, wheezing, grunting, retracting, “singing”
Use of Accessory Muscles
Indicates respiratory distress
Ex: intercostal retractions, substernal retractions

34. Cardiovascular Heart Sounds Capillary Refill Time Color
Regular rate and rhythm?
Sounds
Murmurs?
Transitional murmur usually a patent ductus arteriosis (PDA). Should resolve spontaneously in hours. Benign finding
Capillary Refill Time
<2 sec
Color
Peripheral cyanosis
Acrocyanosis is a normal finding. Usually resolves by hours of age
Central cyanosis
Abnormal/serious finding. Possible cardiac defect

35. Abdomen/GI Size Shape Contour Bowel Sounds Bladder/bowel Function
Listen to all 4 quadrants. Use proper sequence
Bladder/bowel Function
Should void/stool by 24 hours of life
Meconium
Black and tarry
Cord Status
Discharge, amount, odor? Redness?
Do we clean with alcohol? Check with agency
Current research states cleaning with alcohol does not decrease infection rates

36. Umbilical Cord Look for 2 arteries and 1 vein
Use “AVA” to help you remember

37. Significance of a 2-Vessel Cord
Instead of 2 arteries and 1 vein the newborn has only 1 artery and 1 vein
Could be completely benign
However since the umbilical cord is developed at the same time as the fetal kidneys during gestation, the nurse should monitor urine output after birth
If urinary output is adequate, very likely that the 2-vessel cord is of no significance

38. Assessing the Umbilical Cord
Can you see the 3 vessels?

39. Genitalia General Appearance Vaginal Discharge Urinary Meatus
Pseudo-menses (bloody vaginal discharge) related to withdrawal of maternal hormones
Edematous labia is a normal finding
Urinary Meatus
Hypospadias: meatus on underside of penile shaft rather than at the tip
No circumcision until consult with pediatric urology. Foreskin will be used to correct
Undescended Testes
Testes have not descended into the scrotum
Hydrocele
Fluid in scrotum. Related to birth trauma and/or maternal hormones. Resolves spontaneously

40. Assessing for Descended Testes
Place gentle pressure on either side of the base of the penis. (This prevents the testes from retracting into the inguinal canal during palpation)
Palpate the right scrotum. Feel for a very moveable, hard marble-like mass
Repeat in the left scrotum
If both testes detected, document that “testes have descended into the scrotum”
If undescended, document and notify pediatrician

41. Extremities Muscle Tone Flexion Femoral Pulse Clubfoot Webbing
Hypotonic, hypertonic, jittery
Flexion
Degree of flexion, ROM, hip dysplasia/clicks
Femoral Pulse
Present, absent, bilateral
Clubfoot
Webbing
Polydactally
More than 5 fingers/toes

42. Assessing for Congenital Hip Dysplasia

43. Simian Crease

44. Neuro/Reflexes Reflexes: Babinski Reflex Plantar Reflex Sucking Reflex
Stroking sole upward and across ball of foot elicits fanning and extension of toes
Plantar Reflex
Curling of toes when sole touched
Sucking Reflex
When object placed in mouth or touches lips. Usually develops at 37 weeks gestation
Rooting Reflex
Turns head when cheek stroked. Cue that infant is hungry
Palmar or Grasp Reflex
Wraps fingers around your finger
Moro or Startle Reflex
Extremities extend and flex with loud noise or sudden loss of equilibrium. Infant forms a “C” shape with thumb and forefinger

45. Rooting Reflex Sucking Reflex

46. Palmar and Plantar Reflexes

47. Babinski Reflex

48. Startle or Moro Reflex
Do you see the “C” shape of the fingers?

49. Spine Inspect/Palpate Spine Sacral Dimple/Tuft of Hair
Straight; flexible?
Normal curvature?
Sacral Dimple/Tuft of Hair
Indicates possible neural tube defect such as spina bifida
If the sacral dimple is closed, usually a benign finding
If the sacral dimple is open and deep, document and report to the pediatrician. Anticipate an order for diagnostic tests such as an MRI or CT scan

50. Sacral Dimple

51. Anus Sphincter Tone Patency -A bowel movement confirms patency
-Some agencies discourage routine rectal
temperature taking because of risk of
perforating the bowels
-A rectal temperature (core temp.) is
always required if infant appears ill/septic

52. Elimination Patterns Satisfactory Elimination Patterns
First 24 hours at least 1 wet diaper and 1 stool
By day 3 at least 3-4 wet diapers and 1-2 stools (change from meconium to yellowish color)
Day 4 (after milk has come in) > 6-8 wet diapers and at least 3 stools per 24 hours
Must void after circumcision before being discharged to ensure no injury to urethra

53. Measuring the Newborn Head: Chest: Length:
Place the measuring tape at the level of the eyebrows
Chest:
Place the measuring tape at the level of the nipples
Length:
Run the tape along the side of the body from the top of the head to the soles of the feet

54. Measuring the Newborn

55. Weighing the Newborn Done at birth and then every 24 hours
Place blanket or blue chux on scale
Zero out the weight
Place naked infant on scale
Record in lbs/oz and also in grams
Ensure you have a secure hold on the baby when moving to/from the scale!

56. Weighing the Newborn

57. MCC iTunes
Visit MCC iTunes>Nursing>Obstetrics to see a video on a neonatal assessment