1. NEWBORN ASSESSMENT Alicia A. Stone RN,MS,FNP
Assistant Professor of Nursing
Molloy College

2. Everyone is kneaded out of the same dough
but not baked in the same oven.  ~Yiddish Proverb

3. Nursing Objectives To promote physical well-being. Nursing care
Physical assessment
Nutrition
To promote and establish a functioning family.
Support
Education

4. Fetus to Newborn: Respiratory Changes
Initiation of respirations
Chemical surfactant reduces surface tension 34-36wks decrease in oxygen concentration
Thermal sudden chilling of moist infant
Mechanical compression of fetal chest during delivery normal handling
p.484
Physical compression of fetal chest during deliveryFetal fluid lungs is forced out intot he upper air passages.
Chemical surfactant reduces surface tension 34-36wksdecrease in oxygen concentration
Thermal sudden chilling of moist infant
Tactile stimuli normal handling
Initiation of Respirations
A. Development of the lungs
1. Fetal lung fluid is essential for normal development of lungs
2. Lung fluid shifts to interstitial spaces near term
3. Surfactant is produced as lungs mature
a. Reduces surface tension within alveoli
b. Alveoli collapse without surfactant
c. Surfactant usually sufficient by 34 to 36 weeks of gestation
B. Causes of respirations (Figure 19-1)
1. First breath must force fluid into interstitial spaces
2. Requires negative pressure
3. Initiation of respirations
a. Chemical factors
1) Chemoreceptors respond to changes in blood chemistry
2) Changes in level of blood gases stimulate respiratory center
3) Prolonged hypoxia can interfere with initiation of respiration
b. Thermal factors
1) Temperature change at birth stimulates initiation of respirations
2) Skin sensors respond to temperature change
c. Mechanical factors
1) Chest compression during passage through birth canal
2) Some lung fluid is forced out of lungs during birth
3) Tactile stimuli during birth stimulate skin sensors
4. Continuation of respirations
a. Surfactant keeps alveoli partially open between respirations
b. Air from first breath becomes residual capacity
c. Subsequent breaths require less effort
d. Remaining fluid is absorbed into circulatory and lymphatic systems

5. Apgar Scoring

6. Neurologic Adaptation: Thermoregulation
The maintenance of body temperature is a major task for the NB infant (normal temperature is )
1) their skin is thin and blood vessels are close to the surface
2) they have little SQ fat to serve as a barrier to heat loss
3) they have 3x the surface to body mass as an adult
4) Preterm infants are especially susceptible to heat loss because their tone is poor and they have even less fat and thinner skin than full term babies.

7. Methods of Heat Loss
1) Evaporation-occurs when wet surfaces are exposed to air.
2) Conduction- occurs when the NB comes in direct contact with objects that are cooler than their skin.
3) Convection- occurs when heat is transferred to air that surrounds the NB.
4) Radiation- occurs when there is a transfer of heat to cooler objects that are not in direct contact with the infant.
See picture on page514

8. Convection Radiation Evaporation Conduction 1. Preventing heat loss
a. Prepare radiant warmer for neutral thermal environment
b. Avoid stress of maintaining body temperature
c. Check equipment before delivery
2.Providing immediate care
a .Dry infant quickly
b. Important to dry head and cover with a cap
c. Replace wet towels or blankets
d. Attach skin probe to regulate temperature of radiant warmer
3.Providing ongoing prevention
a. Warm all items that contact infant
b. Position infant away from walls or windows to reduce heat loss
c. Avoid exposing body of infant
4.Restoring thermoregulation
a. Initiate nursing measures if temperature decreases
b .Investigate cause for low temperature
c. Add warmth with clothes or blankets
d. May need to return to radiant warmer
Conduction

9. The distribution of brown adipose tissue (brown fat) in the newborn.
Nonshivering theromgenesis. Primary method of heat production in infants
Sound only in newborns
Found in back of neck, anillae, around the kidney, adrenals and sternum, between the scapula and along the abdominal aorta.
C. Non shivering thermogenesis
1. Newborns rarely shiver
2. Metabolic rate increases in response to falling skin temperature
3. Begins oxidation of brown fat to produce heat
a. Brown fat found only in newborns (Figure 19-4)
b. Contains an abundant supply of blood vessels
c. Metabolism of brown fat generates more heat than other fats
d. Blood passing through brown fat is warmed
e. If brown fat stores are not available, cannot raise body temperature
4. Begins when thermal receptors detect a drop in skin temperature
5. Allows body to maintain internal heat at an even level
Nonshivering thermogenesis The distribution of brown adipose tissue (brown fat)

10. Effects of Cold Stress
1) Metabolic Rate: leads to  use of glucose and  production of Surfactant. This can lead to hypoglycemia and respiratory distress.
2) Non-Shivering Thermogenesis-metabolism of Brown fat. This leads to increased production of free fatty acids, which leads to metabolic acidosis and jaundice.
3) Vasoconstriction: leads to pale, mottled skin and shut down of pulmonary vessels, which leads to fetal circulation patterns.

11. Bonding
Kennell and Klaus
En face
Encourage Breastfeeding
Skin to skin

12. Periods of Reactivity First Period (30-60 minutes)
Vital signs, Color, Eyes wide open.
Encourage attachment (Bonding)
Apgar Scoring, radiant warmer
Medications
Sleep Phase (1 – 4 hours)
Second Period (4 – 12 hours)
Intense sensitivity to internal and external stimuli.
Void and meconium
Watch mucus, apnea, emesis

13. Nursing Assessments Vital signs Measurements Gestational Age
Medications
Glucose levels
Temperature stabilization.
What is a successful transition???

14. General Survey Appearance
Symmetry, any obvious deformities, size, smell, muscle tone, sex, posture
Behavior
Crying, lethargic, responsive, reflexes, jittery

15. Measurements Normal Weight 2500-4000gms 5 ½lbs. – 8lbs, 13 oz.
(AGA-appropriate for gestational age)
Below normal (SGA- small for gestational age)- <10%
Above normal (LGA-large for gestational age)- >90%

16. Normal Length- 18-22” or 48-52 cm.
Head circumference ” or cm. (measure right above eyebrows)
Chest circumference ” or 30-34cm (measure at nipple line)

17. Vital Signs
Temperature- first is usually taken axillary, but may be taken rectally to assure anal patency ( C or F)
Pulse bpm, unless sleeping (100) or crying (180)
Respirations with periodic breathing
B/P- only if suspected heart problem or premature infant

18. Gestational Age Assessment

19. Physical Characteristics of Gestational Age

20. Medications in the Delivery Room
Vitamin K (Aquamephyton)
Erythromycin Ointment

21. FONTANELLES
Bulge – IICP
Depressed – dehydration

22. Molding
Overriding sutures.
Resolve quickly

23. Caput Succedaneum Soft tissue edema from birth trauma.
Crosses suture lines.

24. Cephalohematoma
Bleeding between the cranial bone and the periosteum in periosteal space.
Does not cross suture lines
What will happen when it starts to resolve?

26. SKIN
Reddish in color, smooth, puffy.
Edema
Turgor
Cord
Nails

27. Acrocyanosis
Mottling
Jaundice

28. 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.

29. Vernix
Milia

30. Rashes/Marks Erythema Toxicum (Newborn Rash) Forcep marks
Mongolian spots
Birthmarks:
Port wine stain
Stork bite/Nevi
Strawberry mark
Café au lait
Petechiae

31. Erythema Toxicum
Mongolian spot
Forcep mark

32. Port wine stain
Stork bite/ Nevi
Strawberry hemangioma

33. Eyes Check color, red reflex. Subconjunctival Hemorrhage
From birth trauma
Chemical Conjunctivitis from a reaction to eye prophylaxis.

34. Ears Pinna top on horizontal line with outer canthus of eye
Loud noise elicits Startle Reflex
Flexible pinna with cartilage present

35. Nose EXPECTED FINDINGS COMMON VARIATIONS
Nostrils patent bilaterally Obligate nose breathers No nasal discharge
COMMON VARIATIONS
Sneezes to clear nostrils Bridge appears absent Thin white nasal mucus discharge
Signs of potential distress or deviations from expected findings
Malformation Nasal flaring beyond first few moments after birth

36. MOUTH AND THROAT Mucosa moist Palate high arched
Well developed fat pads bilateral cheeks
Sucking, rooting, gag, and extrusion reflex.
Epstein’s pearls, thrush, supernumerary teeth, cleft palate

37. Cleft lip and palate

38. 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
Apical Pulse, check for retractions, grunting

39. ABDOMEN Expected Findings
Dome-shaped abdomen Abdominal respirations Soft to palpation Well formed umbilical cord Three vessels in cord Cord dry at base Liver palpable 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 hours of birth

41. GENITALIA
FEMALE
Edematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia
MALE
Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voiding

42. EXTREMITIES
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 and sole creases evident

43. POLYDACTYLY
Count the fingers and toes. Open the hand and look!

44. HIP DISLOCATION Ortolani’s manuver Unequal leg length
Asymmetrical skin creases posterior thigh

45. CLUB FOOT Talipes Equinovarus When the foot turns inward and downward
Check for normal positioning and whether it corrects easily.
May be positional.

46. 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
Moro reflex
Signs of potential distress or deviations from expected findings
Hypotonia Quivering Limp extremities or straightening of extremities Clonic jerking Paralysis

47. BEHAVIORAL
Observe how the baby quiets to soothing, cuddling, or wrapping
Sleep-wake cycles.
Brazelton Behavioral Assessment Scale.
Watch for excessive crying, fretfulness, and inability to quiet self (Drug Withdrawal)

48. ADDITIONAL CARE Suctioning Positioning Wrapping Holding
Circumcision Care
Newborn Testing
PKU, T4
Hearing

49. PARENT EDUCATION Axillary temp Bathing Care of nails Diapering Feeding
Health care provider visits
When to call for immediate attention.