week 2 Newborn Assessment (lab day 4)

A term baby is any baby delivered between 37 and 42 weeks gestation.

• A preterm baby is defined as < 37 weeks.
• A postterm baby is defined as > 42 weeks.

Apgar Score

false, the apgar score is performed by the nurse at 1 and 5 minutes.

8 or higher

< 8 requires intervention

• 1. HR
• 2. resp
• 3. muscle tone
• 4. reflex response
• 5. color

axillary temperature of a newborn should be between 97.7 - 99.1

Newborn apical pulse range is 120-160 bpm

newborn respirations = 30-60/min

false, the newborn's blood pressure varies with gestational age and is not routinely taken on well babies. That said, the range is systolic 65-95 and diastolic is 30-60

• 1. respirations
• 2. apical pulse
• 3. temperature

• 1. hold thermometer lengthwise against the baby and place into the armpit
• 2. hold the arm firm against the baby's body
• 3. do not force into the armpit
• 4. do not hold thermometer upright

• 1. assess for s/s of infection
• 2. Is the baby dressed too warmly?
• 3. Is the warmer too hot?

• 1. If low at first, take again
• 2. if temp is 97.6 take interventions like wrapping the baby in 2 blankets
• 3. recheck in 1/2 hour
• 4. if it remains low, put baby in a warmer
• 5. check blood glucose for hypoglycemia
• 6. check for s/s of infection
• 7. check for s/s of a CNS deficit

hypoglycemic newborn would have a blood glucose level <= 40 (blood obtained by a heel prick).

hypoglycemia in a newborn could mean infection, CNS problem, or a cold room.

• false, count for a full minute
• observer color of lips and tongue, any blue report immediately

• 1. color of lips and tongue, any blue should be reported immediately
• 2. chest movements for symmetry
• 3. respiratory distress - nares flaring, grunting, chest retractions
• 4. tachypnea > 60 bpm (could be due to labor)
• 5. apnea - due to the baby being cold, or due to infection/sepsis

• nares flaring
• grunting sounds
• chest retractions

apical

120-160 bpm

true

4th

• > 160 bpm
• could mean the newborn is experiencing
• 1. respiratory problems
• 2. anemia
• 3. infection

• < 120 bpm
• could be a sign of
• 1. asphixia
• 2. increased ICP
• 3. sometimes the baby's HR just goes down if he's sleeping

Brachial

5 lbs 8 oz - 8 lbs 13 oz (2500 - 4000 grams)

• AGA - appropriate for gestational age
• LGA - large for gestational age
• SGA - small for gestational age

false, the baby loses 10% of weight in the first 3 - 5 days because the baby is still adapting and learning how to survive on it's own. The baby is losing fluids while learning.

This weight should be regained by 2 weeks.

• A. head circumference: 32 - 38 cm
• B. chest circumference: 30 - 36 cm (measured at the nipple line)
• C. length: 45 - 55 cm
• D. Abdominal girth (not normally done) 17 3/4 - 21

flexed, clenched, symmetrical, tremors

• 1. hypoxia
• 2. CNS trauma

• low calcium or
• low blood glucose

true

true

false! this could indicate increased intracranial pressure or a neuro deficit

false, this is due to sluggish circulation and will disappear in aprox. 12 hours of life

vernix

lanugo, vernix

lanugo

a bluish color on the periperhal (hands and feet)

acrocyanosis

d. all of the above

dry, cracking and peeling of the skin.

false, lotion will not help desquamation and will resolve itself

white cysts found on the nose, chin, forehead. these are distended sebaceous glands and disappear in about a month.

• this is also known as "newborn rash", or "etox"
• it is benign
• appears as blotchy, red with papules in the center
• they appear in 2-3 days and disappear by day 6
• usually found on the trunk of the newborn

erythema toxicum

milia

false... mongolian spots are common in dark skinned babies

false, they disappear within a couple years

telangeietic nevi

telangietic nevi, aka "stork bites"


usually disappear by age 2

sutures

• anterior
• 4-5 cm

• posterior
• 0.5 - 1 cm

12-18 weeks

8 weeks

true

molding

1 - 2 days

An area of fluid/edema in scalp tissues that crosses over the suture line

false, caput succedaneum is caused by birthing pressure on the skull

soft

within 12 hours

a blood pocket between the periostomy and skull; it is due to trauma; It does not cross the suture line.

• does not cross the suture line
• firm to touch
• slow bleeding
• caused by trauma
• develops at 24 - 48 hours
• reabsorbs slowly on its own over a couple weeks

• 2 well formed, symmetrical ears
• s/b exactly located at level of inner/outer canthus of eye (measure where ear meets head)
• firm cartilage

report anything abnormal at all as this could be a sign of kidney disease (because the ears and kidneys develop at the same time in utero)

• The face should be symmetrical in appearance and movement
• parts proportional and appropriately placed

any transient asymmetry should be reported

• symmetrical
• clear
• scant or absent tears (first 2-4 weeks)
• sclera bluish white
• follows object 180 degrees
• transient strabismus (cross eyed) - due to loss of control of the eye muscles, usually resolves itself in 3-4 months
• edema in eyelids normal

test patency of nares by pressing against on nostril at a time; the newborn should breath without difficulty.

• mouth, gums, tongue pink
• tongue size normal
• tongue moves freely
• lips and palate intact
• sucking pads

a newborn is sometimes born with teeth, these should be removed to prevent aspiration

small white hard cysts in the newborns gums, they disappear without treatment

• short neck
• turns head easily from side to side
• raises head when prone posture
• clavicles intact

• the clavicle should be straight and flat but if it's fractured it may not be.
• It may feel like sandpaper or crepatus which could indicate a fracture.
• limp arm
• crying when arm is moved
• no treatment but to immobilize the arm.

Crepitus: A clinical sign in medicine characterized by a peculiar crackling, crinkly, or grating feeling or sound under the skin, around the lungs, or in the joints.

true

• cylindrical, symmetrical
• xiphoid process may be prominent
• nipples and breast buds are present (feels like a frozen pea)
• breast engorgement, white nipple discharge are normal and due to maternal hormones

abnormal presence of air in the pleural cavity resulting in the collapse of the lung; may be spontaneous (due to injury to the chest) or induced.

free air in the chest outside the lung

pneumothorax

collapse of an expanded lung (especially in infants); also failure of pulmonary alveoli to expand at birth

atelectasis

true. you may hear rales or crackles

• s/b round and soft
• should have positive bowel sounds within the first hour after birth
• umbilical cord - 3 vessels, bluish-white color, no drainage

false, you will see 2 arteries and 1 vein

dries up, turns brown and falls off within 7 - 10 days

• the labia majora is dark; covers clitoris and labia minora
• smegma present - white cheesy found around labia minora - do not wash off, it protects the fragile skin
• clear/white vaginal discharge present
• urinary meatus and vagina present

true, this vaginal bleeding is normal

• true, these tissues protrude from vagina usually in the 1st week of life
• no treatment
• they disappear

• tested descended into the scrotal sac - palpate (feels like a cooked pea)
• rugae should completely cover the scrotum in term babies
• prepuce is nonretractable - do not force
• meatus is at the tip of the penis

Hypospadias is when the meatus is on the underside of the penis

epispadias is when the meatus is on the upper side of the penis

true

• hydrocele is a collection of fluid around the scrotum
• it usually resolves on it's on but can develop into an inguinal hernia so monitor

• true, it is the parents choice
• they should weigh the pros and cons

true

count wet diapers

within 12 - 24 hours

6 -- 10 after day 6

reddish or orange stained urine due to immature kidneys. this should resolve in a couple of days.

• it is the first stool of the newborn, usually within 12 - 48 hours
• black, dark green, sticky, hard to wash off, important to record
• "he mec'd" is a common phrase in OB unit

• breast fed: yellow, sweet smelling, soft stool, 2-3 stools/day
• formula fed: brown, more formed stool, 1-2 stools/day

• flexed, good muscle tone
• equal and bilateral in movement
• correct number of digits
• nail to end of each digit
• palms - 2 transverse creases
• legs equal in length
• gluteal and thigh creases equal
• knee height equal

dislocated hip or hip dysplasia

just one transverse crease across the hand. it indicates a chromosomal disorder.

extra digits

webbing between fingers - surgically corrected

checking the newborns hip/leg sockets - RN's do not do this - only the doctor!

• no openings observed or palpated in the vertebral column
• anus patent
• sphincter tightly closed

• run fingers down the spinal column (should be straight and flat) looking for openings or tufts of hair. This could indicate spina bifida.
• pylanidal dimple or sinus should be reported

a sinus on the newborns base of the spine

the newborn grasps your finger, makes a c-shape with fingers and thumb

when the baby is startled, arms fan outward and inward

• aka, fencing posture
• the baby will flex the opposite arm and leg when in supine position and neck is turned.

stroke foot from the heal up to the toes and this will cause the toes to fan out

when the baby's feet touch a hard surface, the baby lifts leg, looks like they are stepping

turning the head towards the stimulation

putting pressure on the feet will cause the toes to curl. do this after the babinski test.

• alarms built into the clamp on the cord or attached on the ID bracelet
• ID bands to ensure the right baby to the right mother - check every time they are separated/reunited
• nurses wear badges
• baby footprints are taken

• true, babies should sleep on their backs to prevent/decrease SIDS.
• The slogan "back to sleep" is used to encourage this.

if baby just ate, elevate head of bed to prevent aspiration