Newborn Assessment

LEXINGTON COMMUNITY COLLEGEAssociate Degree Nursing

Nursing 235 Client’s Initials ________Spring 1999 Date of Birth ________

Gestational Age ________NEWBORN ASSESSMENT GUIDE

Assessment Textbook InformationPossible Major Deviations and

Complications Infant Observation

I. GENERAL MEASUREMENTS

a. Age Term = start of 38th wk. end of 42nd week.

preterm = before end of 37th wk.posterm = after end of 42nd wk.

b. Weight 6.5-7.75 lbs <6 lbs>9 lbs

c. Length 18-20.5 in45-52.3 cm

d. Apgar Score 7-10 <7

II. HEAD MEASUREMENT

a. Shape Round symmetrical may have molding-->overriding sutures.Slight asymmetry.

Microcephaly <32 cmHydrocephaly >4 cm from chestCephalohematoma

b. Size in relation to body 33-35 cm2 cm> chest circ



c. Fontanels size, shape, consistency

1. Anterior

Sutures, palpableslight

pulsationSoft3-4 cm long2-3 cm widediamond shape

Full bulging, large, depressedClosed sutures

2. Posterior 1-2 cmtriangular

III. EYES

a. Color Grayish blue or gray brown iris. Blue white sclera.

Jaundiced sclera.

b. Movement Random, jerky, uneven. Focus momentarily. Follows to midline.

Gross nystagmusConstant StrabimusDoll’s eye’s > 10 d.

c. Reaction to Light Pupils equal in size, round and reactive to light. May turn toward soft light.

Pupils unequal, restricted, dilated, fixed

d. Tears Without or occasionally. Discharge

e. Evidence of sight Focuses and follows by 15 min of age. See above, reaction to light.

Does not respond to light, focus or follow.



f. Eyelids Size and movement symmetric. Blink reflex. Edema from prophylaxis. Eyes on a parallel plane.

Does not respond to light, focus, or follow.

IV. EARS

a. reaction to noise Startle reflex to loud noise. Attends to sound. By 15 min. of age may move eyes in direction of sound. Responds to crooning by relaxation.

Absence of reaction.

b. Position Line drawn through inner and outer canthi of eye comes to top notch of ear (where it connects with scalp.) Symmetrical.

Low placement

c. Patency Evidence of hearing. Reaction to noise.

V. NOSE Midline

a. Mucus Clear Copius drainage

b. Patency Infants obligatory nose breathers. Sneezing is common.

Cyanosis at rest.Flaring or nares.



c. Reflexes Dependent on state of wakefullness and hunger.

1. Sucking

2. Swallow

3. Gag See Section XXI. REFLEXES

VI. MOUTH SymmetricalPresence of gag and swallowingHard & soft palate in tactEpstein’s Pearls

Mouth drawls to one side

Clefts

VII. NECK

a. Length Short, thick, surrounded by skin folds.

Webbing

b. Mobility Head held midline. Free movement from side to side. Full flexion and extension. Cannot move head past shoulder.

Rigid.Restricted movement.Head held at angle.

Without head control.

VIII. CHEST

a. Size 1-2 cm <head circ.30-33 cm

<30 cm

b. Breast tissue 3-10 mm breast noduleNipples prominent

Lack of breast tissue



c. Characteristic shape Almost circular.Barrel shaped.

Bulging of chest.Retractions.Bowel sounds in chest.

IX. RESPIRATIONS

a. Rate 30-60/min Tachypnea > 60/minBradypnea < 25/min

b. Rhythm Shallow.Irregular when infant awake.

Labored breathing.

c. Breath Sounds No sounds heard without stethoscope. Grunting, rales, rhonchi, wheeze (with or without stethoscope)

Bronchial. Loud, clear, near. Apnea > 15 sec.

d. Muscular activity involved Simultaneous rise and fall of chest and abdomen. Diaphragmatic and abdominal breathing.

Subcostal and substernal retractions. Flaring of nares. Chin tug.

X. PULSE

a. Rate 120-160/min.180 with crying 100/min. if asleep

Persistent tachycardia-- > 170Bradycardia-- < 120

b. Rhythm May be irregular for brief periods especially after crying.

Persistent irregular rhythm.



c. Peripheral circulation Femoral pulses palpable, equal, strong. Sluggish peripheral circulation.

Weak or absent.

XI. ARMS AND HANDS

a. Length Arms equal in length.Arms longer than legs.

Anelia, phocomelia

b. Movements Spontaneous.Full range of motion.

Limited movements.Asymmetry of movements.

c. Muscle tone Generally flexed. Fist often clenched with thumb under finger.

tonicityAsymmetric contour.Poor tone/floppy.+ scarf sign.

d. Fingers

1. Number Correct Absence of or additional.Short.

2. Webbing Without PolydactylSyndactyl

e. Position Fists often clenched with thumb under finger.

Rigid flexion.Persistent fists.

XII. ABDOMEN

a. Contour Rounded, protruding Abd. distended.Scaphoid.



b. Musculature Not fully developed.Bowel sounds audible 1-2 hours after birth.

Sounds in chest.

XIII. UMBILICAL CORD

a. Number of vessels at birth

2 arteries1 vein

1 artery

b. Appearance Clear, gelatin.Odorless. Drying.

Bleeding or oozing.Drainage or redness.

XIV. GENITAL-URINARY

a. Female Ambiguous genitals

1. Labia Usually edematous

a. Size Covers labia minora Majora widely separated

b. Appearance May have pigment.Symmetric in size.

Minora prominent.

2. Vaginal discharge Absence of vaginal orifice.

a. Color Smegma under labia.May be blood tinged.

Fecal discharge.

b. Type Mucoid/white



b. Male Ambiguous genitals

1. Testes in scrotum Palpable each side.Large. Rugge. Cremasteric.

Undescended.Scrotum smooth.

2. Urethral meatus at end of penis

Correct position.Prepuce covers glans.Not easily retractable.

Not at tip of penis.Adherent prepuce.

3. Circumcised Yes or no.By day 2 white exudate may cover glans penis.

Excessive bleeding, swelling or discharge.

c. Voidings

1. Color Clear, light yellow.

2. Amount Well saturated diapers

3. Frequency By 24 hrs after delivery. At least 3-4 times/day

4. Specific gravity 1.008-1.010

XV. RECTUM

a. Patency Good sphincter tone of anus. Good wink reflex.



b. Stools

1. Number Meconium by 24 hrs. after birth. Failure to pass meconium.

2. Color

3. Consistency

Depends on age of infant and type of feeding she is receiving.

Abd. distention.Diarrhea—curdy, green, large water ring, forceful.

4. Frequency See your book for specifics.

XVI. HIPS

a. Symmetry Gluteal folds even Congenital hip dysplasia

b. Femur heads IntactNo protrusion.

XVII. BACK

a. Appearance Straight, easily flexed.

b. Turns head from side to side in prone position.

YesCan raise head momentarily.

Limitation of movement. Pigmented nevus with tuft of hair located at base of spine.Spina bifida.

XVIII. LEGS AND FEET

a. Appearance May appear to have bowed legs.



1. Warmth Equal Different temps.

b. Length Legs of equal length.Shorter than arms.

Unequal

c. Movement Full ROM Hypermobility.Lack of leg movement.

d. Alignment Foot in straight line.May appear to turn in but easily rotated externally.

Club foot.

e. Muscle tone General flexion

f. Toes Feet flat. Well lined over 2/3 of surface.

1. Number Correct Absent or excessive digits.

2. Webbing Without Syndactyly

g. Position General flexion. Most often see legs drawn up against abd.

Rigid or floppy posture.

XIX. SKIN

a. Color Generally pink.Acrocyanosis. May see some mottling.

Jaundice.Cyanosis.Pallor or dark red.



b. Textures Smooth, soft. Flexible.May have dry peeling hands and feet.Without edema.

Thinner or thicker texture.Fish scale skin.

c. Birthmarks TeleangiectasesMongolian spots.Transient hyperpigmentation of areolas, genitals.

Hemangiomas

d. Characteristics

1. Milia Distended sebaceous glands particularly on nose and cheeks.

2. Lanugo Over shoulder, pinnias, forehead, back.

Absent or excessive.

3. Vernix caseosa White, cheesy, odorless. In creases and folds.

Absent of excessive. Yellow, green or foul odor.

4. Ecchymosis Peteciae over presenting part. Ecchymosis from forceps.

Over other areas.

5. Hair Amount varies. Silky, growth pattern toward face and neck.

Fine, woolly. Coarse, brittle. Unusual growth pattern.



6. Nails Present, extended beyond fingertips. Absence.

7. Peeling Of hands and feet at about day 3. Generalized cracking and/or peeling.

XX. TEMPERATURE

a. Normal 97.6-98.6 axillary <97 Ax.>99 Ax.

b. Temperature regulatory mechanism

Shivering mechanism undeveloped. Brown fat.

Temp not stabilized by 10 hrs after birth.

c. Heat Loss From evaporation, conduction, convection, radiation.

Swings of > 2 F from one reading to the next.

XXI. REFLEXES

a. Local

1. Blink Response to light stimulus. Tap on forehead, bridge of nose, maxilla when eyes open—blink first 4-5 times.

Continued blinking with repeated taps.

2. Pupillary Response to light is equal. Round. Pupil constricts.

Failure to respond. Response unequal.



3. Doll’s eyes When head is turned, eye movement lags behind.

4. Rooting Turns head in direction of stimulus, opens mouth.

Weak or absent.

5. Sucking/swallowing Follows rooting. Takes hold, sucks ad obtains fluids.

Weak or absent. Gagging, coughing or vomiting with swallowing.

6. Gag Safety reflex. Do not try to elicit.

7. Yawn Spontaneous.

8. Grasp Finger curl around examiner’s finger. Toes turn downward.

9. Babinski Hyperextension of all toes with dorsiflexion of big toe when one side of sole is stroked from heel across ball of foot to toe.

Absent.



b. Generalized

1. Moro (Startle) Symmetric abduction and extension of arms.Finger may fan with forefinger and thumb forming a C. Arms then adduct in embracing motion and return to relaxed flexion.

2. Tonic neck (fencing) When head is turned to one side, extremities on same side extend and on opposite side flex.

3. Dance/Walking when held upright with one foot touching a flat surface, will stimulate walking. Will step alternately.

Asymmetry of stepping.

4. Crawling While on abdomen, will make crawling movements with arms or legs.

Absent.

c. Assess the newborn for:

1. Presence or absence of each reflex.

2. Strength of each reflex.

3. Infant’s response to your assessment.

Assessment Textbook InformationPossible Major Deviations

and Complications Infant Observation

XXII. CRY

a. Frequency Individual, 15-20 min q. 24 hrs to 2 hrs q. 24 hrs.

Unconsolable

b. Pitch Lusty, strong. Moderate pitch. High pitch. Weak or absent.

XXIII. PERSONALITY AND BEHAVIOR

a. Response to handling Touch, massaging, warmth--> soothing

b. Reactions to environment Low pitch voice--> relaxation. Responds with quietness and increased alertness and cuddling, voice.

Unconsolable

c. Parent-infant interaction Turns head and focuses when interested. Coordinates body movement to parent’s voice and body movement.

No focus on person handling.

d. Eating-Sleeping patterns Variations in interest/ hunger. Usually feeds well within 24 hrs. Wakeful periods about q. 3-4 hours.

Lethargy

Documents

Newborn Assessment