1. 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.

2. 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

3. 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

4. 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

5. 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

6. 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

7. General Measurements Head circumference - 33 to 35 cm
Expected findings
Head should be 2 to 3 cms larger than the chest
Chest circumference 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 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)
Length range - 48 to 53 cms ( inches)

8. Skin Expected findings
Skin reddish in color, smooth and puffy at birth At 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

9. 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.

10. 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.

11. 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

12. The Head Expected findings Common Variations
Anterior fontanel diamond shaped cms
Posterior fontanel triangular 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

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

14. 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

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

16. 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

17. 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

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

19. 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.

20. 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.

21. 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.

23. 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.

24. 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.

25. 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

26. 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

27. 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.

28. 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.

29. 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.

30. 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.

31. 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 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
Common variations
Small umbilical hernia

32. 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

33. 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.

34. 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.

35. Genitourinary Kidneys Examined by palpation.
The kidneys should be about 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).

36. 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

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

38. 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

39. 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

40. 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. 

41. 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.

42. 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

43. 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

44. 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

45. 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