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3/21/2018
1
Newborn Assessment
Dr. Susan Ward PhD, RN, LCCE
Lee Ann Caracciolo RN
Outcomes
• Understand newborn history
• Discuss APGAR scoring
• Discuss newborn vital signs, weight and
measurement
• Examine newborn medications
• Explore newborn assessment
• Practice newborn assessment test
questions
History
Antepartum/OB
• Para/gravida • Prenatal care • Previous preterm
births/complications • Medications - Rx,
illicit, over-the-counter, tobacco or alcohol use
• EDC
• Maternal age
• Prenatal care
• Pre-existing medical conditions such as infertility, chronic hypertension…
• High risk factors such as GDM, clotting or seizure disorders
• Antenatal testing
History Intrapartum
• Spontaneous/induction
• Medications
• Membranes ruptured?
• Meconium stained?
• Type of delivery
• Apgar scores
Apgar Scoring (not predictive of neonatal mortality or morbidity)
• Performed at 1 and 5 minutes of age
• If the Apgar score is less than 7 at 5
minutes of age, the Neonatal
Resuscitation Program guidelines state
that the assessment should be
repeated every 5 minutes for up to 20
minutes
• Reflects status of infant and response
to resuscitation
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2
Newborn Vital Signs (37to 41 weeks)
Vital Signs
• Temperature
• Normal axillary is 97.7-99.3 degrees F
• Heart Rate
• Normal range 100-160 beats per minute
• Respiratory Rate
• Normal range 30-60 beats per minute and non-labored
*Count HR and RR for one full minute
Other assessment questions
• Temperature - is the baby overwrapped, just finished nursing or was he snuggling with mom?
• HR- is the baby awake? HR can decrease to 70 bpm while sleeping. Does the HR increase with stimulation?
• RR - what is the baby’s color?
Weight and Measurement • Use a growth chart to determine SGA, AGA, LGA • Weight (average 3405 gm or 7 lbs 8 oz) • Less than 2748 grams (6 lbs) small for gestational age or
preterm, greater than 4050 grams (9 lbs) large for gestational age or infants of diabetic mothers
• Chest circumference
• Measure at level of nipples after exhalation • 30-35 cm (12-14 inches)
• Head circumference • Measure just above eyebrows and around to occipital
prominence in back of skull • 32 to 37 cm (12.5 to 14.5 inches)
• Length • Measure top to head to heel
• 48 to 52 cm (18 to 22 inches)
Medications Vitamin K (phytonadione)
• Every newborn receives a single parenteral dose (IM) of natural Vitamin K1 (phytonadione) 0.5 to 1 mg
• Prophylaxis and treatment of Vitamin K deficiency bleeding (VKDB)
• Coagulation factors (II, VII, IX, & X) formed in the liver
• Requires Vitamin K for final synthesizes.
• Sterile intestinal flora does not allow for Vitamin K synthesis
• Administer shortly after birth
• Oral administration has not shown to be as effective for prevention of late hemorrhagic disease
Eye Prophylaxis
• Erythromycin 0.5% ointment is the most effective prophylaxis medication for vaginal and cesarean deliveries against Gonococcal Ophthlamia Neonatorum and Chlamydia
• Administration of eye prophylaxis is required in all states
• The administration of the ointment may be delayed until after initial breastfeeding in the delivery room
• The eye ointment should reach all parts of the conjunctival sac. After one minute the excess medication can be wiped away with a sterile cotton swab or gauze
Hepatitis B Vaccination • Hepatitis B is a contagious liver disease caused by the hepatitis B
virus
• All medical stable babies receive the first vaccine of hepatitis B vaccine before they leave the hospital
• The vaccine acts as a protectant, reducing the newborn’s risk of acquiring the disease from the mother or family members who may not know they are infected with Hepatitis B Virus
• B Vaccine (Engerix-B, Recombivax HB) - the 1st dose of 10 mcg is given IM in vastus lateralis
• Hepatitis B Immuno-globulin (HBIG) - 0.5ml given IM if the mother’s HBsAg status is positive or unknown, within 12 hours of birth
AAP & ACOG (2012, p. 295)
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3
Newborn Assessment
Techniques of Physical Assessment
Assessment Skills
• Observation
• Auscultation
• Palpation
• Percussion
• Translumination
(scrotal sac)
Basic Principles
• First hours of life
• Subtle
signs/symptom(s) – one
sign or a combination of
signs
• Review history for
potential clues
• Quiet environment
• Calm and warm infant
Physical Assessment • Head to toe assessment
– Count umbilical vessels
• Two arteries, one vein
• Report a two vessel cord
– Apgar scoring
– Vital signs
– Weight and measurements
– Medications
– Skin
– Head and neck
– Respiratory system
– Cardiovascular system
– Abdomen
– Musculoskeletal system
– Genitourinary system
– Neurologic system
Skin Assessment
Skin Color and Variations
• Pink, warm and dry are the standard indicators that verify a newborn’s overall health status
• All healthy newborns have a pink tinge to their skin
• The pigment, melanin, is passed on to a newborn by his/her parents and determines skin tone, which can darken overtime based on genetic disposition
• Ruddy skin color is due to the increased red blood cell concentration in the blood vessels and limited subcutaneous fat deposits (plethora)
Skin Assessments and Variations
• Assess for meconium staining
• Inspect the newborn’s back for a closed vertebral column and for any abnormalities (closed” spina bifida or called Spina Bifida Occulta - causes no problems)
• Dimpling
• Tuft of hair
• Masses
• Assess turgor (hydration status)
• Skin should be elastic and should return rapidly to its original shape
Acrocyanosis (bluish color of hands and feet and might be
present in first 24 hours of life)
Circumoral Cyanosis (cyanosis around the mouth)
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Lanugo
• Fine “downy” hair
• Part of gestational age assessment
• At term, Lanugo is only present on
shoulders, forehead and pinna of
ears
• Lanugo in Postmature newborns
is absent
• Lanugo in Premature newborns
is long and thick on the back
and/or shoulders
Vernix Caseosa
• A protective layer or covering (in utero it protects the newborn that is surrounded by amniotic fluid)
• Cheese-like, thick, whitish, substance fused to epidermis
• Vernix Caseosa is visible in the skin folds, creases, axillary and genital areas
• The actual amount found is effected by gestational age
• Note the color – green (meconium stained), yellow (Rh blood incompatibility), foul smell may indicate intrauterine infection that could be passed on to the newborn
Mottling
• Cutis Marmorata or Skin Mottling is a “lacy pattern” on
the skin and occurs as a result of general circulation
fluctuations. It can last several hours to several weeks.
Mottling may also be related to chilling, prolonged apnea,
sepsis or hypothyroidism
• Capillary refill is > 3 seconds is abnormal – provides
information about the infant’s cardiac perfusion
Skin Color and Variations
Jaundice (physiological or Icterus
Neonatorum) results from the accumulation
of bile pigments and associated with an
excessive amount of bilirubin in the blood. Is
worsened by ecchymosis – forcep marks,
severe caput, cephalohematomas, bruising
due to trauma. Seen in 30-50% of all normal
term newborns
Skin Color and Variations • Hyperbilirubinemia
– Occurs within the first 24 hours of life
– The Total Serum Bilirubin (TSB) increases by 0.5 mg/dL per hour or 5mg/dL per day
– The diagnosis is made when the TSB concentrations climb ≥ 12.9 mg/dL in a term infant and ≥ 15/mg/dL in a preterm infant
– Visual observation is first noticed in the head and gradually progresses to the thorax, abdomen and extremities
– Use the Transcutaneous bilirubinometry (TcB) which is non invasive way to get a more accurate then visual reading of the infant’s bilirubin level
Skin Color and Variations
• Administer phototherapy (the level of bilirubin determines if the newborn is placed under single, double or triple phototherapy). Side effects of phototherapy are loose watery stools, diaper rash and dehydration
• Fiber optic systems (Bili Blanket) can also deliver phototherapy in a blanket form placed under or around the newborn
• During phototherapy cover the newborn’s eyes and genital area to prevent retinal and tissue damage. Remove the mask during feedings and shut off the lights
• Monitor the newborn’s temperature closely for hypothermia
• Excess bilirubin is excreted through the stools
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Harelequin Sign
Difference in color of half of the face or body (Harlequin’s sign) generally related to immature hypothalamic center
Flushing occurs on dependent side (this newborn was placed on right side before the current supine position)
Mongolian Spot
(Congenital Dermal
Melanocytosis)
The most common pigmented lesion in newborns
Mistaken for a bruise due to gray/green color
Location is the buttocks, flanks, or shoulders
May fade over time
Milia - raised white
spots on the face and
nose
Epstein Pearls -
whitish-yellow cysts
that form on the gums
and roof of the mouth
Bohn’s Nodules - grayish
white lesions in this newborn's
mouth that resolve spontaneously
Forcep Mark
• Pressure marks are typically red or bruised areas from the use of forcep on the face, scalp, and/or cheeks
• Examine the infant thoroughly or note other complications such as skull fracture, fractured clavicle, facial palsy
Erythema Toxicum Neonatorum Newborn rash (cause unknown) –a
pale yellow colored papule or
pustules that vary in size from 1 to 3
millimeters
Most commonly found on the trunk
and diaper area and is widespread
but does not appear on the palms of
the hands or the soles of the feet
May appear quickly and may last up
to 3 months of life – no treatment is
necessary
Accessory Nipple(s)
• Accessory or supernumerary nipple(s) can be single or multiple, flat, tan or brown spots along the “milk line” below and medial to the true nipple(s)
• Often darken at puberty
• Diagnosed when dimpling occurs when adjacent skin is stretched away from the nipple(s)
• May also be associated with glandular tissue
• A whitish secretion from the nipples may also be noted. The infant’s breast should not be massaged or squeezed because this practice may cause a breast abscess
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6
Common or Simple Nevus
“Birth Mark”
• The color of a nevus depends upon the amount of melanin or skin pigment
• A dark brown or black macule commonly seen on the lower back or buttocks
• Nevi may be associated with hair. Flat Nevi without hair rarely need removal
• If the Nevi or tufts of hair are found in sacral area– it is associated with Spina Bifida Occulta
• Some Nevi can have malignant changes and should be observed closely for changes in size or shape
Cafe`au Lait Spot
(means “coffee with milk”)
• Tan or brown in color
• Oval-shaped macule (flat)
• If less then 3 cm or less than 3-5 in number,
there is no pathologic significance
• The presence of 6 or more spots >.5 cm in length
may indicate cutaneous Neurofibromatosis (an
autosomal dominant disorder in which tumors of
various sizes form on peripheral nerves)
Capillary Hemangiomata or
Port Wine Stain
Also known as “Nevus Flammeus” (flat, red purplish color) • Does not blanche with pressure • Soft and compressible with poorly defined borders • Will not grow or spontaneously disappear but may
get darker and thicker with time • If convulsions or other neuralogic problems
accompany the Nevus Flammeus, it is suggestive of Sturge-Weber syndrome with involvement of the 5th cranial nerve
Capillary Hemangioma
Nervus Simplex or Telangiectatic Nevi
• Common in newborns – appear as pink or red spots.
Common in light complexioned newborns and are more
noticeable during periods of crying
• Generally found on nape of neck, lower occipital area,
eyelids, above upper lip
• Blanche with pressure
• Fade spontaneously by end of first 2 years – no treatment
necessary
https://www.medicinenet.com/image-
collection/lymphedema_picture/picture.htm
Link to photo of
Capillary
Hemangioma
Infantile Hemangioma
Also called Nevus Vasculosus
Former name was “Strawberry Mark”
Bright red, raised tumor typically on the head, neck, trunk, or extremities The lesion may grow quickly for about six month then slowly begin to regress, it may take several years to completely go away
Newborn Assessment
Head, Neck, Face, Eyes, Ears,
Nose and Mouth
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7
Head
• The head may appear egg shaped due to molding that occurs with a vaginal delivery – this condition usually resolves within a few days to weeks of life
• Inspect and palpate the infant’s skull and identify bones, sutures, fontanels for size and symmetry of head. Is there presence of molding, caput, and/or bruising?
• Palpate suture lines
• Palpate cranial bones
Craniotabes (softening or thinning of the skull)
• Usually this is due to external pressure from
prolonged vertex engagement or pressure of the
fetal head on the uterine fundus with a breech
presentation
• Palpate skull for softening of cranial bones
• When palpating the area will collapse and then
recoil, the sensation is similar to pressing on a
ping pong ball
• This condition resolves in a few weeks if this is
due to external pressure and not a metabolic or
underlying disease process
Fontanelles
Palpate the Fontanelles
• Assess with newborn sitting and not crying
• The fontanelles may swell with crying or passage of stool
• Depressed anterior fontanelle may indicate dehydration
• Bulging fontanelle may signify increased intracranial pressure or infection
• Fontanelles may be smaller immediately after birth than several days later
• Posterior fontanelle
• Smaller and triangular
• Closes within 8 to 12 weeks
• Anterior fontanelle
• Diamond shaped
• Closes within 18 months
Molding
• Overlapping of cranial bones during labor and delivery
• Type of delivery will impact shape and the
amount of molding will depend on much
pressure was placed on the head
• Head circumference usually returns to
normal within 2 to 3 days after birth and
the suture lines become more palpable
• A baby born by cesarean or breech will
usually have a more symmetrical shaped
head
Breach
head
Vaginal
Delivery
Cephalohematoma
• Bleeding into space between the bone and
periosteum
• Appears on first and second days of life
• May be unilateral or bilateral
• Doesn’t cross the suture lines
• Common in a vertex birth
• The scalp may feel loose and somewhat edematous
Caput Succedaneum
• Usually due a difficult labor or use of a vacuum
extractor (vacuum extractor may cause a circular
shape and take longer to resolve)
• The fluid is reabsorbed in about 12 hours to a few
days after delivery
• There is a slow venous return which may cause increase in tissue fluids, edema and sometimes bleeding under the periosteum
3/21/2018
8
Subgaleal Hemorrhage
Potentially this condition
is the most serious effect
from birth trauma but it is
the least common
Signs and Symptoms
• Generalized scalp edema
• Usually with ecchymosis
• Bilateral or unilateral periorbital edema
• Ballotable fluid crosses suture lines
• Firm to fluctuant tension
Periosteum
Bone
Skin Subgaleal hematoma
Subgaleal Hematoma formation
Neck
Assess:
• Symmetry
• Is there full range of motion?
• Appearance – is it normal or does the neck have a short and thick appearance ?
• Torticollis
– Contraction of neck muscle pulling head to one side
– May be congenital or occur during the birth process
– Results from injury to sternocleidomastoid muscle
• Cystic Hygroma
– Cyst usually on lateral neck
– If it is large it can deviate the trachea and cause respiratory distress
Face
• Observe for symmetry, bruising and/or
petechiae
• Observe for congenital syndromes
• Assess when the newborn is crying
• If it was a forceps delivery, assess for injury:
• Facial nerve palsy (7th cranial nerve)
• Drooping mouth appearance
• Decreased movement on affected side of
face
Eyes • Assess eyes for symmetry in size and shape
• Eyes and/or eyelids may be edematous after birth
• Eye color
• Usually slate gray, brown, or dark blue
• Eye color becomes permanent after 6 months of
age
Sclera
• Usually bluish – white in color
• May have Subconjunctival Hemorrhages which
usually resolve in a week
• If the sclera is yellow further assess for
hyperbilirubinemia
Eyes
• Are there tears present? Tears are usually absent until the duct becomes fully patent at 4 to 6 months of age
• Prominent epicanthal folds are normal in Asian infants but may suggest Down Syndrome
• During the opthalmoscopic exam assess:
• Red reflex, is it present?
• Red reflex, is it absent?
• Suggests congenital glaucoma or cataracts
• Pale red reflexes are a normal variation in dark-skinned newborns
• Are the corneas and lens intact?
Eyes
• Strabismus
• Cross eyed appearance often seen in newborns
• Nystagmus
• Rapid, searching movement of the eye
• Usually disappears by 4 months of age
• Newborns can see objects clearly at 8 to 10 inches in front of them
• Newborns are nearsighted at birth
• Respond to bright or primary colors
• Respond to high contrast such as black and white
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Abnormal Eye Assessment Persistent purulent discharge
• Opthalmia Neonatorum (conjunctivitis, neonatal eye infection)
• Chlamydial Conjunctivitis • Blocked tear duct • Chemical Conjunctivitis (getting smoke, liquids, fumes,
or chemicals in the eye)
Blue sclera • Osteogenesis Imperfecta
Sclera visible above iris (sunset eyes) • Hydrocephalus
Pupils unequal, fixed, and nonreactive • Neurologic insult
Keyhole shaped pupil (coloboma - is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc)
• Syndrome associated anomalies
Ears Assess:
• Ear position – draw an imaginary line from inner to outer canthus of eye toward ear
• If insertion falls below line, it is low-set
• Genetic syndromes
• There may be temporary asymmetry from intrauterine position
Breastfeeding Atlas 3rd ed.
EARS
Benign variations shown are:
A. Pre-auricular sinus
B. Prominent (protruding)
ears
C. Darwin’s Tubercle
D. Incomplete Helix
development (seen mostly
with premature infants–
final ear cartilage
development in last 4
weeks of gestation)
A B
C D
Ears
Normal vs. Low Set
• Initial embryonic ear development by mandible with
upward progression during fetal development
• Low set placement of ears seen with
• genetic syndromes (i.e., Trisomy 13, 18, 21)
• abnormal development of internal organs –
especially Potters’s Syndrome (renal agenesis)
Nose
• Symmetric and midline
• May see nasal stuffiness and thin, white mucus immediately after birth
• Sneezing is normal
• Assess for bilateral nasal patency
• By alternately obstructing one nares then the other
• If necessary, insert 5 French catheter to check patency
Abnormal Nose Assessment
Findings • Flat nasal bridge
• Pink when crying, chest
retractions and
cyanosis at rest,
difficulty feedings
• Stuffy nose and thin,
watery discharge
• Persistent “sniffles” with
profuse mucopurulent
or bloody discharge
Pathology
• Down syndrome
• Choanal atresia
• Neonatal drug
withdrawal
• Congenital syphilis
(Simpson & Creehan, 2014 p 606 Table 19-5)
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10
Mouth
• Symmetrical
• Sucking blisters may be present
• Mucous membrane pink- assess for cyanosis
• Increased amount of mucus during first two days of life
Mouth (Tongue)
Ankyloglossia or “Tongue Tie” - restricts
the tongue's range of motion
• The lingual frenum attaches superior to
normal placement– possibly to tip of tongue
• Only treated if problems with feeding or
speech
Macroglossia or enlarged tongue
• Seen with metabolic problems (i.e.,
Hypothryoidism)
• Seen with genetic defects (i.e.,
Trisomy 21, gargoylism or dwarfism)
Breastfeeding Atlas 3rd ed.
Breastfeeding Atlas 3rd ed.
Mouth
Microganthia (condition in which the jaw is
undersized)
• Seen in Pierre Robin Sequence (a set of
abnormalities affecting the head and face)
• Hypoplasia of the mandible
Natal teeth
• One or two natal teeth
• Usually are loose
• Usually removed so newborn cannot aspirate
Uvula
• Should be midline
• Bifid uvula (divided by a deep cleft or notch into two parts)
Breastfeeding Atlas
3rd ed.
Abnormal Mouth Findings • Weak, uncoordinated suck/swallow
• Prematurity
• Neurological disorder
• Maternal analgesia during labor
Excessive drooling and salivating
• Unable to pass NG tube
• Esophageal Atresia (the upper esophagus ends and does
not connect with the lower esophagus and stomach)
• Thin upper lip, flat philtrum (cleft in the middle area of the
upper lip)
• Fetal alcohol syndrome
Abnormal Mouth Findings
• Dry mucous membranes
• Dehydration
• Cyanotic mucous membranes
• Central cyanosis
• Frantic sucking
• Infant of drug-addicted mother
• Patches of white on tongue and mucous membrane
• Candida Albicans (Thrush)
Respiratory
Newborn
Assessment
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11
Fetal Lung Fluid
• Typically by 34-36 weeks of gestation the fetus
has produced enough surfactant to maintain
alveolar stability
• The absorption of the fetal lung fluid is speed up
during the labor and delivery process, and
during a vaginal delivery about 1/3 of the fluid is
expelled due to the thoracic squeezed from
coming out the birth canal
Fetal Lung Fluid • After delivery, in preparation for extrauterine
life, the infant expands his/her lungs that stimulates the release of surfactant which helps decrease the surface tension within the alveoli
• The first breath of air by the infant causes fetal circulation to convert to neonatal circulation
• When the infant draws in air, the lungs expand, pulmonary vascular resistance declines which then causes pulmonary vasodilation and an increase in blood flow to the lungs
First Breath Four factors will influence the initiation of the infant’s first
breath
1. Sensory - There are several tactile, visual, and auditory stimuli for the infant once the newborn enters the outside world which help with the initiation of the first breath
2. Chemical - The three chemical factors are- hypercarbia, acidosis, and hypoxia. These three chemical factors are brought on through the stress of labor and delivery and stimulate the respiratory center in the brain to initiate breathing
First Breath (Continued)
3. Mechanical - The fluid in the lungs is removed and replaced with air, which is the primary mechanical factor in the initiation of respirations
4. Thermal - There is a radical drop in temperature going from in utero to the outside world, sensors in the skin respond to the temperature change and send signals to the respiratory system in the brain to initiate respirations
Respiratory Assessment
• Average respiratory rate is 30 to 60 bpm
• Respirations are typically shallow and irregular
• Periodic breathing is a pause in respiratory movements that lasts for up to 20 seconds alternating with breathing. This can be more common in preterm infants but can occur in term infants
• It is not common to have skin color changes or heart rate changes
• Chest movement should be symmetrical
• Diaphragmatic breathing is normal
• Observe color – cyanosis
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Respiratory Assessment
Lung sounds
• Louder and courser in newborns because there is less
subcutaneous tissue
• Fine crackles (rales) may be heard in the first few hours
after birth and has also been associated with Acute
Respiratory Distress Syndrome and Bronchopulmonary
Dysplasia
Newborns have periodic breathing patterns due to immaturity of respiratory and central nervous systems
• It is not unusual to see brief pauses in respiratory effort
Apnea
• Pauses in respirations lasting 20 seconds or longer
• If associated with color change or bradycardia, report to the health care provider immediately
Abnormal Respiratory Findings
Tachypnea
• Respiratory rate greater than 60 bpm (no oral feedings)
Respiratory distress
• Retractions, flaring, grunting
• See-saw movement of chest and abdomen
Retractions
• Drawing back of the chest wall with inspiration and occur when the accessory muscles are used for breathing. In the chest, common sites for retractions include suprasternal, supraclavicular, intercostal, subcostal, and substernal
Assess the infant’s respiratory status including increasing respiratory rate and decreasing oxygenation
Clavicles
• Should be smooth and straight
• Palpate for fracture
• Crepitus (grating sound) may be felt
Breasts
• Hypertrophy of breast tissue may be present by second or third day of life
• May or may not have a milky secretion due to maternal hormones (do not massage breasts)
• Breast engorgement usually subsides in 1 to 2 weeks
• Supernumerary nipples may be present but benign
Newborn Assessment
Neonatal
Circulation
Newborn Assessment
Fetal Circulation
Fetal Circulation https://www.youtube.com/watch?v=8WX0POOZhvE
See shunt closure
• Oxygenated blood from inferior vena cava enters right atrium,
through to left atrium then left ventricle and on to ascending aorta
where it is directed to fetal heart and brain
• Superior vena cava drains deoxygenated blood from head and
upper extremities into right atrium where it mixes with oxygenated
blood from the placenta
• Blood enters right ventricle and pulmonary artery where the
resistance in the pulmonary vessels causes 60% of this blood to be
shunted across the ductus arteriosis and into the descending aorta
• The mixture of this oxygenated and deoxygenated blood continues
through the descending aorta oxygenating the lower half of the fetal
body and eventually draining back into the placenta through the 2
umbilical arteries…the remaining 40% of the blood coming from the
right ventricle perfuses lung tissue to meet metabolic needs
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Abdomen
Newborn Assessment
Abdomen
• Bowel sounds are audible at 15 minutes after birth, but are faint/quiet until feeding begins
• Normally rounded and symmetric (measure circumference)
• Protuberant and soft
• Easy movement up and down associated with respirations
• Chest and abdomen should rise at same time
• If asynchronous (see-sawing) it can indicate respiratory distress
• After 36 weeks gestational age, abdominal circumference is greater than head circumference
Abnormal Abdominal Assessment Diastasis Recti (separation of the abdominorectus muscle) - is
not uncommon
• Can be seen as a midline, elevated ridge from below the
sternum to the umbilicus when newborn is crying
• Due to newborn’s weak abdominal muscles
• Resolves without intervention • A sunken or scaphoid abdomen
May indicate a diaphragmatic hernia or dehydration
• Normal preterm infant
May appear distended due to lack of muscle tone
• Term infant
May have decreased muscle tone due to maternal
medications received in labor
Abnormal Abdominal Assessment
• Prune Belly
• Congenital absence of abdominal musculature
• Associated with severe renal and UTI abnormalities
• Markedly distended abdomen may indicate bowel obstruction
• Umbilical Hernia
• Common finding in 30% of term African American infants
• Also seen in low birth weight males
• Close spontaneously by 2 years of age
Umbilical Cord
• Shiny, pearly white, and gelatinous
• A yellow or green cord may indicate meconium
staining occurred 6 to 12 hours prior to delivery
• Two arteries, one vein
• Wharton’s jelly protects vessels
• Indicator of infant’s nutritional status
• Any unusual bulging in cord is evaluated
• Usually falls off in 10 to 14 days
Omphalitis (infection of the cord)
• Redness encircling the cord and extending into the abdomen
• Must be treated promptly
• May indicate a small Omphalocele (a birth defect in which an infant's intestine or other abdominal organs are outside of the body. The intestines are covered by a thin layer of tissue and can be easily seen)
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Newborn Assessment
Perianal Area
• Inspect for presence and placement of anus
• Patency established by passage of meconium
• Usually within 24 – 48 hours of birth
• If anus is absent it suggests Anal Atresia
• Passage of small stool suggests stenosis
Musculoskeletal System
Newborn Assessment
Musculoskeletal • Position
• Flexion of both upper and lower extremities
• Symmetrical
• Asymmetrical
• Possible injury related to birth trauma
• Presence of abnormal movements
• Count fingers and toes
Musculoskeletal
• Look for extra or missing digits and webbing
• Syndactyly
• Congenital webbing of fingers and toes
• May be familial
• Polydactyly
• Extra digits
• Palpate clavicles for fractures
• May feel crepitus or a lump
• Assess for normal muscle tone
Brachial Plexus Injury
• Associated Factors/Risks
• Shoulder dystocia has also occurred in
newborns delivered by cesarean without labor
• Positioning in utero
• Large babies
• Breech position
Brachial Plexus Injury • Injury to Brachial Nerve Plexus
• Erb’s palsy
• Complete or partial paralysis of the shoulder muscles as a result of C5 and C6 neurologic injury
• Grasp reflex intact but Moro reflex is absent on affected side
• Klumpke’s
• Involves C8 and T1 injury
• Complete or partial paralysis of forearm and hand muscles
• Complete paralysis of arm
• Treatment
• Aimed at preventing contractures
• Usually resolves in 3-6 months
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15
Phrenic Nerve Paralysis
• Controls diaphragm
• Usually associated with Brachial injury
• Usually unilateral
• Position on the affected side because otherwise
respiratory effort is impaired
• Pneumonia often occurs
Avulsion (complete disconnection of nerves)
• Permanent damage
• Graft surgery may be an option
Extremities
Polydactyly and Syndactyly
• Polydactyly or Super-numerary digits
• Occur on hands or feet
• Most common upper extremity anomaly
• Skin tag (ligation) verses complete appendage (surgery)
• Syndactyly - is abnormal fusion of the digits or “webbing”
• Usually found in 3rd and 4th fingers and/or 2nd and 3rd toes
• Requires surgical repair
Developmental Dysplasia of the Hip
(DDH) • Risk factors:
• Family history • Oligohydramnios • Breech presentation • Foot deformities • Primiparity • Female sex • Multiple pregnancy
• Assess • Asymmetric gluteal folds • Ortolani maneuver
• A palpable clunk is noted when abducting the hip • Barlow maneuver
• Clunk palpated when thigh adducted
Performing the Barlow Test (steps 2 and 3) and Ortolani’s
Maneuver (step 4)
1. Place the infant supine on a flat surface
2. Place your thumbs on the infant’s inner thigh and your fingers
on the outside of the greater trochanters of the hips
3. Flex the infant’s knees and move the legs inward until your
fingers touch
4. Use genital but firm pressure, rotate the hips outward so the knees touch the surface
*No clicking or crepitus should be heard
Extremities
Hip and Sacral Assessment
• Pilonidal Dimple
• A pilonidal dimple is a small pit or sinus in the sacral area just at the top of the gluteal fold (crease between the buttocks)
• It may also be a deep tract leading to a sinus and cyst that may contain hair
• May grow and the cyst may drain during
adolescence (possible surgery)
Extremities
HIP and Sacral Assessment
Spina Bifida Occulta
• An abnormal hair growth, lipoma, capillary hemangioma over the thoracic or lumbar spine
• A dermal sinus or small tract which leads from the skin surface down through to the spinal cord
• Blind sinuses or pits which do not lead into the spine are common (up to 25%) and do not indicate underlying problems
• Only 2% of infants who have Spina Bifida Occulta have any symptoms or problems
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Extremities Assess ankles and feet for positional and structural
malformations
• Positional
• Metatarsus Adductus
• Inward turning of front one third of foot
• Talipes Calcaneovalgus
• Leg and foot form shape of a checkmark rather
than an L
• Structural
• Club foot (Talipes Equinovarus) - sole of foot turns
medially and foot is inverted
• The most severe form of “Club Foot” is fixed in
position by bone and requires lengthy orthopedic
treatment
Newborn Assessment
Genitourinary System
Genitourinary • Genitalia is part of gestational age assessment
• Assess for ambiguous genitalia
• If present, refer to infant as “baby”
• Watch for and document first voiding
• Should void within 24 hours of delivery
• A rust colored stain on the diaper is a normal variation and caused by uric acid crystals in the urine
• Genitourinary anomalies and abnormalities in other
systems may be found i.e. cardiovascular, neurologic,
gastrointestinal and/or musculoskeletal conditions
• If there is a history of oligohydramnios or
polyhydramnios there is most likely a genitourinary or
renal impairment
Female Genitourinary
• A white mucous discharge from vagina is
not uncommon during the first week of life
• Pseudomenstruation
• Pink-tinged mucous discharge
• Caused by withdrawal of maternal
hormones
• Lasts 2 to 4 weeks
Male Genitourinary
Physiologic Phimosis
• Inability to retract the prepuce or foreskin at birth
• By 3 years of age, foreskin can usually be retracted in
90% of uncircumcised males because adhesions
loosen
• In the uncircumcised penis the foreskin should not be
retracted or forced away from the tip of the penis during
bathing or diaper care AWHONN, 2013 Skin Care Guideline
Male Genitourinary Undescended Testes (Cryptorchidism)
• Most common genital abnormality
• May be unilateral or bilateral
• Will usually descend by 9 months of age in term males
Hypospadius
• Second most common genitourinary abnormality
• Meatus is on the ventral surface of the penis
• In some cases, associated with congenital syndromes
Epispadius
• Meatus is on the dorsal surface of the penis
Hydrocele
• Enlarged scrotum from accumulation of fluid
• Should disappear in 3 months
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Male Genitourinary
Testicular Torsion
• Twisting of testis on its spermatic cord
• May occur prenatally
• Usually unilateral
• Hard, swollen scrotum which is red to bluish red in color and
does not transilluminate
• Compromises blood supply to testes
• Requires urgent evaluation and possibly emergency
management
• Ischemia of more than 4-6 hours duration usually
results in irreversible damage of loss of the gonad
• Pain is not a universal finding in neonates
Newborn Assessment
Neurologic System
Reflex Elicit the reflex Normal Abnormal
Suck By gently stroking the lips the
newborn
Newborn will open his/her mouth
and sucking movements begin
Weak or absent response is seen with
premature infants, neurologic deficit,
or CNS depression from maternal drug
ingestion
Rooting Stroke the cheek and corner of the
newborns mouth
The newborn’s head should turn
toward the stimulus and open their
mouth
Weak or absent response is seen with
premature infants, neurologic deficit,
or CNS depression from maternal drug
ingestion
Palmar Grasp Stimulate the palmar surface of the
newborn’s hand with a finger
The newborn should grasp the finger
and if the finger is pulled away the
infant should lead to a tighter grasp
If the grasp is weak or absent in a
term newborn then cerebral, local
nerve, or muscle injury may be
present
Tonic Neck Turn the newborn’s head to one side
when the newborn is resting in supine
position
Extremities on the side the head is
turned will extend and the opposite
extremities will flex
May indicate a neurologic injury if this
is a persistent response after four
months
Moro Hold newborn in the supine position
with head several centimeters off the
bed, then withdraw the hand
supporting the head so the infant’s
head falls back into the examiner’s
hand. Or expose to a loud noise.
The newborn will abduct and flexes all
extremities and may cry
An absence may indicate neurologic
deficit or deafness
Babinski Stimulate the sole of the foot Extension or flexion of the toes occur Consistent absence of any response is
abnormal and may indicate central
depression or abnormal spinal nerve
innervation
Neurological and Behavioral Assessment
• Assessment through observation - alertness,
resting posture, quality of muscle tone, motor activity and cry
• A typical position for the newborn is partially flexed extremities and legs abducted to the abdomen
• Purposeless movements
• Muscle tone
• Tremors
• Jitteriness
• Neonatal seizure
6 Normal
Sleep-Wake Cycles At term the infant spend almost 50% of his/her total sleep in active sleep and 45% in quiet sleep and about
10% is the transitional sleep between the two periods
Description of Sleep-Wake Cycles Picture A shows a newborn in deep or quiet sleep
Picture B shows a newborn in the period of active rapid eye movement (REM). At term the infant spend almost 50% of his/her total sleep in active sleep and 45% in quiet sleep and about 10% is the transitional sleep between the two periods. Depending on the newborns age the amount of time spent in each sleep cycles will vary
Picture C shows a newborn in the drowsy or semidozing state. The newborn may have open or closed eyes, fluttering eyelids, slow and regular movements of the limbs. They tend to have a delayed response to external stimuli
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• Picture D shows the quiet alert or wide awake state. The newborn is fully alert and follow objects, faces, or auditory stimuli, but limited motor activity and still a delay in response to external stimuli
• Picture E shows the active alert state. The newborns eyes are open, intense motor activity such as thrusting limbs, environmental stimuli increases the motor activity
• Picture F shows the crying state. There are jerky movements and intense crying. The newborn may be hungry or in pain so the crying is used as a distraction and helps the newborn disburse energy and get a response from care givers
Periods of Reactivity First Period of Reactivity
Lasts about
30 minutes
after delivery
Heart rate and
respirations are
rapid
May have some
nasal flaring and
grunting
Muscles tone
and motor
activity are
increased
Body
temperature is
decreased
Periods of Reactivity
Second Period of Reactivity
The newborn
wakes and is alert
Will show signs of
wanting to eat
More responsive
to stimulation
Tachycardia,
tachypnea, rapid changes in color
and muscle tone
Increased oral
mucus
Practice Questions 1. The nurse is assessing the neonate’s skin and notes the
presence of small irregular red patches on the cheeks that will develop into single yellow pimples on the chest and/or abdomen. The name for this common neonatal skin condition is:
A. Erythema toxicum
B. Milia
C. Neonatal acne
D. Pustular melanosis
Feedback: Erythema toxicum is a newborn rash that consists of small, irregular flat red patches on the cheeks that develop into singular, small yellow pimples appearing on the chest, abdomen, and extremities. Acne, a skin condition common in adolescents, may also be present in newborns and is related to excessive amounts of maternal hormones. Over time, neonatal acne disappears spontaneously from the infant’s cheeks and chest. Milia presents as small white papules or sebaceous cysts on the infant’s face that resemble pimples. Pustular melanosis is a condition in which small pustules are formed prior to birth. As the pustule disintegrates, a small residue or “scale” in the shape of the pustule is formed, and this lesion later develops into a small (1 to 2 mm) macule, or flat spot. Macules, which are brown in color, appear similar to freckles and are frequently located on the chest and extremities. Pustular melanosis occurs more commonly on African American infants than on Caucasian infants.
2. The nursery nurse notes the presence of diffuse edema on baby girl Patel’s head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant’s chart:
A. Caput succedaneum
B. Cephalhematoma.
C. Epstein pearls
D. Subperiosteal hemorrhage
Feedback: Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant’s head and persists for weeks while the tissue fluid is slowly broken down and absorbed. Epstein pearls are whitish, hardened nodules on the gums or roof of the mouth.
3. The perinatal nurse teaches the new mother and her family about appropriate infant care to prevent omphalitis. Information given would include:
A. Instructions for taking a rectal temperature
B. Instructions to keep the base of the umbilical cord clean and dry
C. Instructions to apply a mild soap and water solution to the cord
D. Instructions to change the diaper frequently during the first 24 hours following circumcision
Feedback: The area around the base of the cord should be kept clean and dry. During diapering, care must be taken not to allow stool or urine to come in contact with the cord or the cord base. If this occurs, the nurse (or care giver) should carefully clean and dry the site. The tissue surrounding the base of the cord should be inspected for redness because this finding may indicate omphalitis, an infection that is readily treated with antibiotics.
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4. The perinatal nurse is aware that if a respiratory rate of 68 breaths per minute is noted in the newborn, the appropriate nursing actions would include: (Select all answers that apply)
A. Withholding the feeding
B. Continuing assessment of the infant’s respiratory rate and color
C. Notifying the physician of additional signs or symptoms of respiratory distress
D. Documenting the infant’s chest measurement
Feedback: For healthy full-term neonates, a respiratory rate below 60 breaths per minute is considered normal. To obtain an accurate respiratory rate, it may be necessary to count the infant’s respirations at several different times during the physical assessment. If the respiratory rate remains above 60 to 70 breaths per minute during rest, further evaluation is warranted. The nurse should withhold oral feedings if the respiratory rate is greater than 60 respirations per minute. Additional signs of respiratory distress, such as flaring of the nares, retractions (in-drawing of tissues between the ribs, below the rib cage, or above the sternum and clavicles), or grunting with expirations should be reported to the physician.
5. As the perinatal nurse performs an assessment of the infant’s head, ears, eyes, nose, and throat, the ears are noted to be low set. This clinical finding would require follow up due to the potential for _________ _______.
Answer: Chromosomal abnormalities
Feedback: Special attention is paid to the shape, size, and placement of the ears. Low-set ears may signal the need for further assessment and evaluation for chromosomal abnormalities. Placement of one ear slightly lower than the other is a common finding that generally has no clinical significance.
6. During the physical examination of a male neonate, the perinatal nurse notes that no bowel sounds can be auscultated. The best action following this discovery is ________, a technique used to assess for the presence of ______ in the scrotal sac.
Answer: Transillumination; fluid
Feedback: If no bowel sounds are heard, transillumination can be used to verify the presence of fluid in the scrotal sac. The nurse secures a penlight or ophthalmoscope, which will be used as a light source, darkens the room, and gently presses the light source against the scrotum. Fluid appears as a reddish-yellow reflection. Masses do not transilluminate and, if detected, must be reported immediately.
7. During the newborn assessment, the nurse notes asymmetry of the skin folds of the infant’s thighs in both the prone and supine positions. This finding may be an indication of ______
Answer: Hip dysplasia
Feedback: Developmental dysplasia of the hip is a congenital condition that if left untreated can affect the infant’s future ability to walk and maintain balance. It occurs when the acetabulum is flat, rather than round and cup-like in shape. The assessment begins with inspection of the skin folds on the infant’s thighs in both the prone and supine positions. Asymmetry of the skin folds may signal the presence of hip dysplasia.
References
Davidson, M., London, M., & Ladewig, P. (2016). Old’s
Maternal Newborn Nursing & Women’s Health Across the
Lifespan (10th ed.). Boston, MA: Pearson.
Mattson, S., & Smith, J. (2016). Core Curriculum for Maternal-
Newborn Nursing (5th ed.). St. Louis, MO: Elsevier.
McKee-Garrett, T. (2016) Overview of the routine
management of the healthy newborn infant. In M. Kim (ed). Up
to date retrieved from http://wwwuptodate.com/home
References
Simpson, K., & Creehan, P. (2014). AWHONN Perinatal
Nursing (4th ed.). Philadelphia, PA: Wolters
Kluwer/Lippincott Willams & Wilkins.
Tappero, E., & Honeyfield, M.E. (2015). Physical
Assessment of the Newborn (5th ed.). Petaluma, CA:
NICU Ink.
Tveiten L, Diep LM, Halvorsen T, Markestad T.
Respiratory Rate During the First 24 Hours of Life in
Healthy Term Infants. Pediatrics 2016; 13
http://newborns.stanford.edu/RNMDEducation.html
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References
Verklan, M. T. (2015). Adaptation to extrauterine life. Chapter 4 in Verklan and Walden AWHONN Core Curriculum for Neonatal Intensive Care Nursing, 5th edition. St. Louis: Elsevier Saunders
Venes, D. (2017). Taber's Cyclopedic Medical Dictionary, 23rd Edition (Thumb Index Version) 21st Edition. Philadelphia: F.A. Davis
Ward S. & Hisley (2016). Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children and Families (2nd ed.), Phildelphia: F. A. Davis
Ward, S. (2013). Pediatric Nursing Care: Best Evidence-Based Practices. Philadelphia: FA Davis.