1. New Ballard Scale
    • infant maturity rating scale that assesses neuromuscular and physical maturity. Number assigned from -1 to 5. Then a classification is made:
    • LGA- large for gestational age (90th percentile)
    • AGA - appropriate for gest age (10th-90th percentile)
    • SGA - small for gest age (below 10th percentile)
    • LBW - low birth weight (2500g or less)
    • VLBW- very low birth weight (1500g or less at birth)
    • IUGR- rate of growth does not meet expected norms. (Intrauterine growth restriction)
  2. Newborn vital signs
    • Norms
    • Resp rate: 30-60/min w/ short periods of apnea (less than 15 sec) occurring mostly during REM sleep
    • HR: 100-160 beats/min w/brief fluctuations above and below for crying, sleeping, etc.
    • BP: 60-80/40-50
    • Temp: 36.5 to 37.2 C (97.7 to 98.9 F) axillary
  3. Normal deviations in newborn physical assessment:
    Mongolian spots
    Telangiectatic nevi
    Nevus flammeus
    Erythema toxicum (erythema neonatorum)
    Epstein pearls
    • Milia- small raised white spots on chin, nose, forehead
    • Mongolian spots- bluish purple spots of pigmentation usually on back, shoulders, buttocks. More often on dark skinned infants.
    • Telangiectatic nevi- aka stork bites. flat pink or red mards that easily blanch. Found on neonate's upper eyelids, back of neck, and middle of forehead. Usually fade by 2nd year of life.
    • Nevus flammeus - aka port wine stain. Capillary angioma below surface of skin that is red or purple. Varies in size and shape and is commonly on the face. Does not blanch or disappear.
    • Erythema toxicum- pink rash that appears suddenly anywhere on the body of a term neonate during first 3 wks. No treatment required.
    • Epstein pearls- small white cysts on gums and at junction of soft and hard palates
  4. Caput succedaneum
    Normal localized swelling of the soft tissues of the scalp caused by pressure on the head during labor. May cross over teh suture line. Usually resolves in 3-4 days and doesn't require treatment.
  5. Cephalohematoma
    Collection of blood between the periosteum and the skull bone that it covers. Does not cross suture line. Results from trauma during birth in prolonged difficult labor or with use of forceps delivery. Appears first 1-2 days after birth and resolves in 3-6 wks. At highter risk for jaundice.
Card Set
Nursing newborn assessment and other information