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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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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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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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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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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

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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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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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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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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.