1. New Born Vital Signs Designed By: Dr. Areefa Al-Bahri

2. Vital Signs Temperature - range 36.5 to 37 axillary 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 - 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

3.  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 Strider  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

4. 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 Molding  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)

5. Skin  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 caseosa Lanugo 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 Vernix caseosa Lanugo

6. Common variations  Acrocyanosis - result of sluggish peripheral circulation Mongolian spots in infants of African-American descentMongolian spots

7.  Mottling Mottling Physiologic jaundice

8.  Milia Milia Erythema toxicum Petechiae/ bruises over presenting part Skin tags usually around ears or digits (tied off) Harlequin color changePetechiaebruises Harlequin color change

9.  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 Jaundice

10. Head  Expected findings  Anterior fontanel diamond shaped 2-3 - 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat Sutures palpable with small separation between each

11. Common variations  Caput succedaneum Caput succedaneum Molding of fontanels and suture spaces

12.  Signs of potential distress or deviations from normal findings  Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalhematoma Cephalhematoma  Closed sutures

13. 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

14. Common variations  Edematous eyelids Uncoordinated movements May focus for a few seconds

15. 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 Reflexes absent Subconjunctival hemorrhage "Doll's eyes"

16. 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

17. Nose  Expected findings  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  Choanal atresia and discharge Malformation Nasal flaring beyond first few moments after birth

18. Mouth and Throat  Expected findings  Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips. Palate high arched Uvula midline Minimal or absent salivation Tongue moves freely and does not protrude Well developed fat pads bilateral cheeks Sucking reflex Rooting reflex Gag reflex Extrusion reflex

19. Common variations  Epstein's pearls on ridges of gums  Signs of potential distress or deviations from expected findings  Cleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete Protruding tongue Candida Albicans  Diminished tongue movement Percocious teeth

20. Neck  Expected findings  Short and thick Turns easily side to side Clavicles intact Tonic neck reflex present Neck-righting reflex present Some head control  Signs of potential distress or deviations from expected findings  Torticollis-stiff neck drawing head to one side Resistance to flexion Webbing of neck Large fat pad on back of neck Palpable crepitus, movement with palpation of clavicle

21. 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

22.  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

23. 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

24.  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

25. Female Genitalia  Expected findings  Edematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia  Common variations Pseudomenstruation 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  Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia

26. Male Genitalia  Expected findings  Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous Stream adequate on voiding  Common variations Increased pigmentation Edema and ecchymosis after breech delivery  Signs of potential distress or deviations from expected findings  Non palpable testes Hypospadius Scrotum smooth Ambiguous genitalia

27. 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 Imperforate anus Anal fissure

28. 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

29.  Sole creases present  Negative hip click Grasp reflex present  Signs of potential distress or deviations from expected findings  Unequal tone Asymmetrical movement of extremities Polydactyly

30.  Syndactyly Unequal leg length Asymmetrical skin creases posterior thigh  Dislocation of hip  Simean crease Persistent cyanosis of nail beds Marked metatarus varus

31. Neuromuscular System  Expected findings  Maintains postion 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

32. References: Burns, C.E., Barber, N., Brady, M.A., Dunn, A.M., (1996) Pediatric Primary Care: A Handbook for Nurse Practitioners, Philadelphia, W.B. Saunders Company. Gorrie, Trula Myers, McKinney, Emily Stone, and Murray, Sharon Smith. (1994). Foundations of maternal newborn nursing,Philadelphia; W. B. Saunders Company. Wong, Donna L. (l995). Whaley & Wong's nursing care of infants and children; contributing editor, David Wilson. 5th edition. St. Louis: Mosby. Variations and minor departures in infants (1994), Mead Johnson & Company: Evansville, Indiana.