New Born Assessment

• Temperature
• 36.5^o-37.5^o C (97.7^o-99.5^o) axillary
• 36.5^o-37.6^o C (97.7^o-99.7^o) rectal
• Axilla is perfered site
• decreased (cold environment, hypoglycemia, infection, CNS problem)
• increased (infection, environment to warm)

• Interventions:
• if decreased:
• institute warming measures and check in 30 min.
• Check blood glucose
• if increased:
• remove excessive clothing
• check for dehydration
• either drcreased or increased:
• look for signs of infection
• check radiant warmer temperature setting
• check thermometer for accuracy if skin is warm or cool to touch
• report abnormals to physician

• Heart Rate: 120-160 BPM (100 sleeping, 180 crying)
• rhythm regular
• PMI at third to fourth intercostal space, slightly to left of midclavicular line, may be visible
• brachial, femral, and pedal pulses present and equal bilaterally

Tachycardia (respiratory problems, anemia, infection, cardiac conditions)

Bradycardia (asphyxia, increased intracranial pressure)

PMI to right (dextrocardia, pneumothorax)

Murmurs (functional or congenital heart defects)

Arrhyrhmias absent or unequal pulses (coarctation of the aorta)

Note location of murmurs refer abnormal rates, rhythms, sounds and pulses

Varies with gestational age

• hypotention (hypovolemia, shock, sepsis)
• defference of 20mm Hg between arms and legs (coarctation of the aorta)

• refer abnormal blood pressures
• prepare for intensive care if very low

• 2500g-4000g
• 5lb 8oz- 8lb 8oz
• weight loss up to 10%
• High (LGA, maternal diabetes)
• Low (SGA, preterm, multifetal pregnancy, medical conditions in mother that affect intrauterine growth)
• Weight loss above 10% (dehydration, feeding problems)

determine cause: monitor for complications common causes

• length 48-53 cm (13-14 inches)
• Below normal (SGA, congenital dwarf)
• Above normal (LGA, maternal diabetes)

• Head Circumference 33-35.5 (13-14 inches)
• head approximately 1/4 of infant's length
• Small (SGA, microcephaly, anencephaly)
• Large (LGA, hydrocephalus, increased intracranial pressure)

• Chest circumference 30.5-33cm (12-13 inches) is2-3cm less then head circumference
• Large (LGA
• Small (SGA)

determine cause and monitor for complications common to the cause

• Normal:
• 1) flexed extremities resist extension, return quickly to flexed state
• 2) hands usually clenched movements symmetric
• 3) slight tremors on crying
• 4) Breech(extended, stiff legs)
• 5) "Molds" body to caretaker's when held
• 6) responds by quieting when needs met

• Abnormal:
• 1) limp flaccid, floppy or rigid extremities (preterm, hypoxia, medications, CNS trauma)
• 2) hypertonic (neonatal abstinence syndrome, CNS damage)
• 3) jitteriness or tremors (ow glucose, or calcium level)
• 4) Opisthotonus, seizures, stiff when held (CNS damage)

• Normal:
• lusty, strong

• Abnormal:
• high pitched (increased intercranial pressure)
• weak, absent, iritable, cat-like, "mewing" (neurologic problems)
• hoarse or crowing (laryngeal irritation)

interventions: observe for changes, report abnormalities

color pink or tan with acrocyanosis.

vernix caseosa in creases (white substance)

small amounts of lanugo (fine hair) over sholders, sides of face or forehead, upper back.

• skin tugor good with quick recoil
• some cracking and peeling of skin

• Normal variations:
• Milia, Erythema toxicum (flea bite rash)
• Puncture on scalp (from electrode)
• monogolian spots
• telangiectatic nevi (nevus simplex or stork bites)

• Color:
• cyanosis of mouth and central areas(hypoxia)

Pallor (anemia, hypoxia)

Gray (hypoxia, hypotension

• red, sticky, transparent skin
• (very preterm)

Ruddy (polycythemia)

Greenish-brown color of skin, nails, cord (possable fetal compromise, post term)

yellow vernix (blood incompatibilities

Jaundice (pathologic if first 24 hrs not good, physilogic if appears after the first 24 hrs)

thick vernix (preterm)

differentiate facial brusing from cyanosis

central cyanosis requires suction, oxygen, and further treatment

refer jaundice in first 24 hrs to the physician

watch for respiratory problems in infants with meconium staining

look for other signs and complications of preterm or post-term birth

record location, size, shape, color, type of rashes and marks

check for facial movement with forceps marks

watch for jaundice with brusing (hematoma)

point out and explain normal skin variations to parents

• bruises on body (pressure)
• scalp (vacume extractor)
• face (cord around neck)
• petechiae (pressure, low paltlets, infection)
• forceps marks

• nevus flammeus (port wine stain)
• nevus vasculosus (strawberry hemangioma)
• cafe' au lait spots (more then six or >1.5 cm in size, neurofibromatosis)

preterm

Post-term

infection

dehydration

Sutures palpable with small separation between each

anterior fontanel diamond shaped, 1-4 cm, soft and flat, may bulge slightly with crying

Posterior fontanel triangular, 0.5-1 cm.

Hair silky and soft with individual hair strands

Normal variations: Overrriding sutures (Molding), Caput succedaneum or cephalhematome (pressure during birth)

• abnormal head assesments:
• head large: hydrocephalus, increased inracranial pressure

head to small: microcephaly

widely spread sutures: hydrocephalus

sutures not palpable: craniosnostosis

anterior fontanel depressed: dehydration, molding

anterior fontanel full or buldging at rest: increased intracranial pressure

woolly, bunchy hair: preterm

unusual hair growth: chromosomal abnormalities

Nursing considerations: seek cause of variations. Observe for signs of dehydration with depressed fontanel, increased intracranial pressure with bulging of fontanel and wide spraration of sutures. Refer for treatment.

Differentiate caput succedaneum from cephalhematoma and reassure parents of normal outcome. Observe for jaundice with cephalhematoma

Ears well formed and complete, area where upper ear meets head even with imaginary line drawn from inner to outer cantus of eye

Startle response to loud noises

Alert to high-pitched voices

• Abnormal assessments:
• Low-set ears: (chromosomal disorders) skin tags, preauricular sinuses dimples (Kidney abnomalies) No response to sound (deafness)

Nursing considerations: check voiding if ears abnormal, look for signs of chromosomal abnormality if position abnormal refer for evaluation if no response to sound deafness

symmetric in appearance and movement, parts proportional and appropriatel placed

• Abnormal assesments:
• asymmetry: pressure and position in utero

drooping of mouth or one side of face "one sided cry" facial nerve damage

abnormal appearance chromosomal abnormalities

nursing considerations: seek cause of variations, check delivery history for possible cause of damage to facial nerve

symmetric, eyes clear, transient stabismus. Scant or absent tears, pupils equal, react to light, alerts to interesting sights. Follows objects 180 degrees. Doll's eye sign, red reflex present. May have subonjunctival hemorrhage or edema of eyelids from pressure during birth

• abnormal assesments:
• inflammation or drainage (chemical or infectious conjunctivtis)

constant tearing (plugged lacrimal duct)

unequal pupils, failure to follow objects (blindness)

white areas over pupils (cateracts)

setting-sun sign (hydrocephalus)

• nursing considerations:
• clean and monitor any drainage; seek cause

reassure parents that subconjunctival hemorrhage and edema will clear

refer other abnormalities to physician

both nostrils open to air flow, may have slight flattening from pressure during birth

• abnormal assessments:
• blockage of one or both nostrils (choanal atresia {blockage of the bone tissue in the nasal passage})

malformations (congenital conditions)

flaring, mucus (respiratory distress)

• Mouth, gums, tongue pink
• Tongue: normal in size and movement
• Lips and palate intact, sucking pads sucking, rooting, swallowing, gag reflexes present

Normal variations: precocious teeth, epstein's pearls (small yellow or white cystic vesicels found in New Born's mouth)

• Abnormal assesments:
• cyanosis (hypoxia)

white patches on cheeks or tongue (candidiasis {yeast})

protruding tongue (down syndrome)

diminished movement of tongue, drooping mouth (facial nerve paralysis)

cleft lip or palate or both

absent or weak reflexes (preterm, neurologic problem)

excessive drooling (tracheoesophageal fistula, esophageal atresia {closure})

• nursing concideration:
• oxygen for cyanosis, expec loose teeth to be removed, obtain order for candidiasis and check mother for vaginal or breast infection refer anomalies to physician

Good suck/swallow coordination retains feedings

• abnormal assesments:
• poorly coordinated suck and swallow. Duskiness or cyanosis during feeding (cardiac defects). Chocking, gagging, excessive drooling (tracheoesophageal fistula, esophageal atresia)

• nursing considerations:
• feed slowly, stop frequently if difficulty occurs, suction and stimulate if necessary refer infants with cintinued difficulty to the physician

short neck turns head easily side to side. Infant raises head when prone. Clavicles intact

• abnormal assesments:
• weakness, contractures, or rigidity (muscle abnormalities)

webbing of neck, large fat pad at back of neck (chromosomal disorders)

crepitus, lump, or crying when clavicle palpated, diminished or absent arm movement (fractured clavicle)

• nursing considerations:
• fracture of clavicle occurs especially in large infants with shoulder dystocia (diffficult dilivery) at birth immobilize arm look for other injuries

cylinder shape xiphoid process may be prominent, symmertic nipples present and located properly. May have engorgement, white nipple discharge (maternal hormone withdrawal)

• abnormal assesment:
• asymmerty (diaphragmatic hernia, pneumohorax)

supernumerary (extra number) nipples redness (infection)

nursing interventations: refer abnormalities to physician

rounded, soft, Bowel sounds present soon after birth, liver palpable 1-3 cm below costal margin. Skin intact. Three vessels in cord (2 arteries and one vein), Clamp tight and cord drying, Meconium passed within 24-48 hours, Urine passed within the first 24 hours

Normal verations: brick dust staining of diaper (urate crystals)

• Abnormal assesment:
• sunken abdomen: diaphragmatic hernia

disended abdomen or loops of bowel visible: obstruction, infection, enlarged organs

absent bowel sounds after first hr: paralytic ileus

masses palpated: kidney tumors, distended bladder

enlarged liver: infection, heart failure, hemolytic disease

abdominal wall defects: umbilical or inguinal hernia, omphalocele, gastrochisis, extrophy of bladder

two vessels in cord: other abnormalities

bleeding: loose clamp

redness, drainage from cord: infection

no passage of meconium: imperforate anus, obsruction

lack of urinary output: kidney anomalies

inadequate amounts of urine: dehydration

nursing interventions: look for other anomalies if only two vessels in cord, tighten or replace loose cord clamp. If stool and urine output abnormal, check to see none was unrecorded, increase feedings,

• Female:
• labia majora dark, cover clitoris and labia minora. Small amount of white mucous vaginal discharge. Urinary meatus and vagina present

Normal variations: vaginal bleeding (Pseudomenstrauation) hymenal tags

• Abnormal assesments:
• Clitoris and labia minora larger than labia majora (preterm)

Large clitoris (ambiguous genitalia)

Edematous labia (breach births)

Nursing interventions: check gestational age for immature genitalia

Testes within scrotal sac, rugae (ridges) on scrotum, prepuce nonretractable. Meatus at tip of penis

• abnormal assesments:
• Testes in inguinal canal or abdomen (preterm, cryptorchidism)

lack of rugae on scrotum (preterm)

edema of scrotum (pressure in breech birth)

enlarged scrotal sac (hydrocele)

small penis, scrotum (preterm, ambiguous genitalia)

urinary meatus located on upper side of penis (epispadias), underside of penis (hypospadias)

nursing interventions: check gestational age for immature genitalia explain to parents why no circumcision can be performed with abnormal placement of meatus

equal and bilateral movement of extremities, correct number and formation of fingers and toes. Nails to ends of digits or slightly beyond, flaxion, good muscle tone

• Abnormal assesments:
• Crepitus, redness, lumps, swelling (fracture)

diminished or absent movement, especially during Moro refles (fracture, nerve damage, paralysis)

• Polydactyly (extra digits)
• syndactyly (webbing), fused or absent digits

poor muscle tone (preterm, neurologic damage, hypoglycemia, hypoxia)

nursing interventions: look for other abnormalities, refer abnormalities to the physician

two transverse palm creases

• abnormal assesments:
• simian crease (crease that extend across the hand instead of two transverse creases there is only one) (down syndrome)

diminised movement of arm with extension and forearm prone (erb-dunchenne) a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the upper trunk C5-C6 is severed

nursing interventions: look for other abnormalities and refer to the physician

Legs equal in length, abduct equally gluteal and thigh creases and knee height equal, no hip "clunck" Normal position of feet

abnormal assesments:

ortolani and barlow test positive unequal leg length (developmental dysplasia of the hip)

Malposition of feet (position in utero, talipes equinovarus {club foot})

nursing interventions: refer all anomalies, look for others check malpositioned feet to see if they can be manipulated back to normal position

No openings observed or felt in vertebral column. Anus patent, Sphincter tightly closed

• Abnormal assesments:
• failure of vertebrae to close (spina bifida)
• with or without sac of spinal fluid and meninges (meningocele)
• or cord (myclomeningocele) enclosed

tuft of hair over spina bifida occulta (hidden) pilonidal dimple (small hole just above the buttocks or sinus imperforate anus

nursing interventions: observe for movement below level of defect. If sac, cover with sterile dressing wet with sterile saline, protect form injury

Moro, palmar and plantar frasp, rooting, sucking, swallowing, tonic neck, babinski, gallant, and steping reflexes present

• abnormal assesments:
• absent, asymmetric, or weak reflexes

nursing interventions: observe for signs of fractures, nerve damage, or injury to CNS