Copy of Normal NewbornAssessment[1]

7/29/2019 Copy of Normal NewbornAssessment[1]

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Normal Newborn

Assessment


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A nurse has completed the assessment ofnewborn who weighs 3,000 g and is 48 cmlong, with a head circumference of 33 cm.His Apgar scores were 8 at one minute and 9at five minutes. Other assessment data

include skin smooth and pink; lanugo present; sole creases covering the entire sole;; well-curved pinna soft with ready recoil; andtestes descended. Reflexs intact; posturefully flexed. The parents express concerns

over his small size.


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Newborn

The great majority of newborn infant have hadanormal intrauterine existance. Infant in normaldelivery are in good condition at birth but have

some veriation in size and shapeand appearancewithin normal, depend on genetic and ethnicfactor.

All newborn should examined at birth to observe

the general condition and to rule out majoranomalies, then the further examination isusually carried out on the third day when thebaby is completely stabilized


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Permit rapid assessment of the need forresucitation .

The test is generally done at one and fiveminutes after birth, and may be repeated

later if the score is remains low. Scores below 3 are generally represent sever

distress and baby need resuscitation , scores

of 4 to 6 fairly low and baby need closeobservation, and over 7 generally normal


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The five criteria of the Apgar score

210Sign

>100beats/min

Slow,


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Vital Signs

Temperature - range 36.5 to 37axillary

Common variations

Crying may elevate temperature Stabilizes in 8 to 10 hours after

delivery


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Heart rate - range 120 to 160 beats

per minuteCommon variations

Heart rate range to 100 when

sleeping to 180 when cryingColor pink with acrocyanosisHeart rate may be irregular with

crying


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Respiration - range 30 to 60 breathsper minute

quite, Effortless diaphragmatic abdominalmore than chest

Common variations Bilateral bronchial breath sounds

Moist breath sounds may be presentshortly after birth


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Blood pressure - not done

routinelyFactors to consider

Varies with change in activity level

Appropriate cuff size important foraccurate reading

Average newborn (1 to 3 days)oscillometry pressure value 65-95/ 30-60 in both upper and lower extremities


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General Measurements

Head circumference33 to 35.5 cm

Measured at top ofeyebrow to widest part of

occiputExpected findings Head should be 2 to 3 cm

larger than the chest

Chest Circumference30.5to 33 cm Measured at nipple line


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Head and chest circumference maybe equal for the first 24 to 48 hours

of life, why??

Common

variationsMolding of headmay result in alower headcircumferencemeasurement
http://www.nursing.duq.edu/newborn/molding.htmlhttp://www.nursing.duq.edu/newborn/molding.html


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Weightrange - 2500 - 4000

gms Lengthrange - 46 to 57 cm

(pilletry)

Measured on supine, Crown-to-heel

head at midline, full

extension of the knees


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General Appearance

Complete flexion alert behavior full range of motion, spontaneous

movementCOMON VARIATION Legs extended with frank breech Drowsiness irritability indicates

(neurological problems)


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Skin

Expected findings

Skin reddish in color,

smooth and puffy atbirth


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Edema around eyes, feet, and genitals

Vernix caseosaa cheesy white material, covers the body

Lanugo

a fine hair, over the entire body Turgor good with quick recoil

Nipples present and in expected locations

without any accessory nipples.Cord with one vein and two arteries*Cord clamp tight and cord dryingwithout any sign of infection
http://www.nursing.duq.edu/newborn/vernix.htmlhttp://www.nursing.duq.edu/newborn/lanugo.htmlhttp://www.nursing.duq.edu/newborn/lanugo.htmlhttp://www.nursing.duq.edu/newborn/vernix.html


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Common variations

Acrocyanosis - resultof sluggishperipheral

circulation


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Mongolian spots ininfants of African-

American descent
http://www.nursing.duq.edu/newborn/mongolian.htmlhttp://www.nursing.duq.edu/newborn/mongolian.html


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Mottling
http://www.nursing.duq.edu/newborn/mottling.htmlhttp://www.nursing.duq.edu/newborn/mottling.html


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Physiologic jaundice
http://www.nursing.duq.edu/newborn/phyjaundice.htmlhttp://www.nursing.duq.edu/newborn/phyjaundice.html


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Miliaenlarged sebaceous glands found on nose, chin, cheeks,and forehead; regress in several days to a week or two.
http://www.nursing.duq.edu/newborn/milia.htmlhttp://www.nursing.duq.edu/newborn/milia.html


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Erythema toxicum

(newborn rash)pink

to red papular rashappearing on trunkand diaper areas;regresses within 48

hours.


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HeadExpected findings Anterior fontanel diamond shaped ,2-3cm

width, 3- 4cm length.

Posterior fontanel triangular about 1 cmlength.

Fontanels soft, firm and flatSutures palpable with small separation

between each


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Common variations

Caput succedaneum

A newbornsscalp often isswollen from

edema andbruising overtheoccipitoparietalregion
http://www.nursing.duq.edu/newborn/caput.htmlhttp://www.nursing.duq.edu/newborn/caput.html


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Molding of fontanels and suture

spacesinfants cranialbones mayoverlap at thesutures to acertain degree,

as a results frompassage of thehead through thebirth canal anddisappears

within 2 days. Itis not seen inbabies born bycesarean section.


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Signs of potential distress or

deviations from normal findings

Fontanels that are bulging or depressedHydrocephalus

CephalhematomaC collection of blood betweenthe periosteum of skull boneand bone it self , its caused by

rupture of preosteal capillarydue to the pressure of bitrh

Usually appears 24 hours afterbirth

Resolved within 2-3 months .
http://www.nursing.duq.edu/newborn/cephalhematoma.htmlhttp://www.nursing.duq.edu/newborn/cephalhematoma.html


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Eyes

Expected findingsGray or blue eye colorNo tearsFixation at times - with ability to follow

objects to midlineRed reflexBlink reflexDistinct eyebrows

Cornea bright and shinyPupils equal and reactive to light


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Uncoordinated movements


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"Doll's eyes"beyond 10

days of agethis Reflex absent

Subconjunctivalhemorrhage

Deviation of normalAccumulation of lacrimal

fluids with secondaryinfection is common

Result from incompletedrainage of nasocramialducts
http://www.nursing.duq.edu/newborn/doll.htmlhttp://www.nursing.duq.edu/newborn/doll.htmlhttp://www.nursing.duq.edu/newborn/doll.htmlhttp://www.nursing.duq.edu/newborn/doll.htmlhttp://www.nursing.duq.edu/newborn/doll.htmlhttp://www.nursing.duq.edu/newborn/doll.html


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Nose

Expected findings

Nostrils patent bilaterallyObligate nose breathersNo nasal discharge

Have a sneeze reflex with or withoutstimulation.


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Mouth and Throat

Expected findings

Mucosa moist.Shortly after birth

may visualizesucking calluses oncentral portions oflips.


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Palate high arched . Uvula midline

. Minimal or absent

.salivation

. Tongue moves freelyand does not protrude

. bilateral cheeks. Sucking reflex

. Rooting reflex

. Gag reflex


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Signs of potential

deviations fromexpected findings

Cleft lip or cleftpalate

Lip movementasymmetricalReflexes absent orincompleteProtruding tongueCandida Albicans


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Precocious teeth


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NeckExpected findings

Short and thickTurns easily side to sideuncoordinated movement: head lag which

disappear at 3-4 month Clavicles intact

Tonic neck reflex present


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ChestExpected findings Evident xiphoid process

Equal anteroposterior and lateraldiameterBilateral synchronous chestmovementSymmetrical nipples

Breath without effort orevident cyanosis

Common variations "Witch's milk"

Enlarged breasts

Accessory nipples


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Abdomen

Expected findingsDome-shaped abdomenAbdominal respirationsSoft to palpationWell formed umbilical cordThree vessels in cord(1 vain & 2 arteries )Cord dry at baseLiver palpable 2 - 3 cm below right costal marginBilaterally equal Brachial, femoral pulses

Bowel sounds auscultated within two hours of birthVoiding within 24 hours of birthMeconium within 24 - 48 hours of birth


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Female Genitalia

Expected findings Edematous labia

and clitorisLabia majora are

larger andsurrounding labiaminora

Vernix betweenlabia

urination within 24hrs

Male Genitalia

Expected findings Urinary meatus at

tip of glans penisPalpable testes in

scrotumscrotum is large,edematous.

urination within 24

hrs


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Back and Rectum

Expected findings

Intact spine without masses or openings Patent anal opening

Anal reflex" present

Passage of meconium within 48 hrs


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Extremities

Expected findings Maintains posture of

flexionEqual and bilateral

movement and toneFull range of motionall jointsTen fingers and tentoes

Negative hip clickGrasp reflex present


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Dislocation of hip


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Dislocated of hip is also called dysplasia of the hip (DDH) True dislocation is rare at birth with notable exception of

the baby. Unstable hip is more common in female except following

breech presentation where the risk is equal in both The method of examination is called Barlow's method The click that you feel it when doing the exam is called

ORTOLANI out in This tow test are just performed in neonatal period, after

age of six weeks these are unpredictable because ofincrease muscle tone


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Central Nervous System

Posture and tone: flexion

Movement: ranging from tremulous

movements of one or all limbs to jitterymovements

Reflexes:


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Neuromuscular System

Expected findings Maintains position of flexion

Able to turn head side to side whenprone

Able to hold head in horizontal linewith back when held prone

Head lag while sitting, with ability to

hold head momentarily erect


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Reflexs Moro Reflex: Sudden change in equilibrium

causes sudden extension and abduction ofextremities and fanning of fingers ,with indexfinger and thumb forming c shape, followed byflexion and adduction of extremities; legs mayweakly flex; infant may cry; disappears after

age 3-4months . Palmer grasp: touching palm of hand near

base of digits cause flexion of hands, lessensafter age 3 months.

planter grasp: touching feet near base of

digits cause flexion to toes, lessens by8months age


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Palmer grasp reflex


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Babniski reflex: stroking outer sole offoot upward from heel and across ballof foot causes toes to hyperextend andhallux to dorsiflex disappears after age1 year

Rooting reflex: touching the cheekalong side of mouth causes infant toturn head toward that side and beginto suck ;disappear at age 3-4 months,may persist for up to 12 months.


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Babinski's Sign ina healthy newborn Moro Reflex
http://en.wikipedia.org/wiki/File:Babinski-newborn.jpg


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Sucking reflex: infant begins suckingmovement of circumpolar area in

response to stimulation ; persiststhoughout infancy , even withoutstimulation ,such as during sleep.

Tonic neck reflex: when infant headis turn to one side, arm and leg extendon that side, and opposite arm and legflex , disappears by age 3-4 months


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Tonic neck reflex


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Swimming reflex :If you were to put a

baby under six months of age in water, they

would move their arms and legs whileholding their breath. This is why somefamilies believe in swim training for very littlebabies. It is not recommended for you to testthis reflex at home for obvious safetyreasons.

Dolls eye reflex :as a head of infant movedslowly to right or left, eyes lag behind anddo not immediately adjust to new position of

head; disappears as fixation developed ifpersists , indicate neurological damage.


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Dance or step reflex: if infant is held sothat the sole of foot touch a hard surface there

is flexion and extension of the leg stimulatingwalking. disappear after age 3-4week.

Startle reflex: sudden loud noise causes

abduction of the arms with flexion of elbow,hand remain clenched ;disappears by age of 4months


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References

Hockenberry, M. J. & Wilson, D. (2004).Wong's Nursing Care of Infants and

Children( 7th ed.). St. Luis, Massouri:Mosby, Inc.

Sandra M. Nettina(1997).

Lippincott Manual of Nursing Practice

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