Normal Newborn�Assessment

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4. Physical assessment of the newborn

Recognize what aspects of the maternal history are important for a complete newborn assessment

• -Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities
• General measurement.
• Vital signs.

Prevention of prenatal

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Objectives

• Recognize what aspects of the maternal history are important for a complete newborn assessment
• Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities
• Learn the basics of a Ballard gestational age assessment
• Understand the importance of gestational age in the complete newborn assessment

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• Recognize what aspects of the maternal history are important for a complete newborn assessment
• Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities
• Learn the basics of a Ballard gestational age assessment
• Understand the importance of gestational age in the complete newborn assessment

• A 90-minute-old term newborn girl has just finished her first breastfeeding. She has been in her mother's arms continuously since birth and now is in a deep, quiet sleep. She is rooming in with her mother in the birthing unit. The vaginal delivery was uneventful and the newborn's APGAR scores were 9 at one minute and 9 at five minutes. Her mother is interested in watching as you begin to perform the initial newborn assessment

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Baby abeer 40-week gestation infant

during nurse assessing apgar score

Skin color was pink all over, Heart rate was 110 , sneeze/cough when stimulated , Muscle tone some flexion

, Respiration was regular�Nurse start physical exam for baby

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Routine examination of the newborn and maternal�satisfaction: a randomised controlled trial�

• D Wolke, S Dave, J Hayes, J Townsend, M Tomlin

4. Physical assessment of the newborn

• Physical assessment of the newborn: table 8-4 p 217-221
• General measurement.
• Vital signs.
• General appearance: Posture,
• Head-to-toe assessment: Skin, Head, Eyes.

Ears, Nose, mouth and throat, neck, chest, � lunge, heart, abdomen, female male genitalia , � back and rectum, extremities.

• Neuromuscular system.

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Newborn�

• The great majority of newborn infant have had anormal intrauterine existance. Infant in normal delivery are in good condition at birth but have some veriation in size and shapeand appearance within normal, depend on genetic and ethnic factor.
• All newborn should examined at birth to observe the general condition and to rule out major anomalies, then the further examination is usually carried out on the third day when the baby is completely stabilized

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• Assessment of the baby condition by using APGAR SCORE

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• The Apgar score must be done at the moment of birth at delivery room, is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two and summing up the five values thus obtained. The resulting Apgar score ranges from zero to 10.

The five criteria of the Apgar score

• The test is generally done at one and five minutes 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 close observation, and over 7 generally normal

Vital Signs�

• Temperature - range 36.5 to 37 axillary

Common variations

• Crying may elevate temperature
• Stabilizes in 8 to 10 hours after delivery

Heart rate - range 120 to 160 beats per minute

Common variations

• Heart rate range to 100 when sleeping to 180 when crying�Color pink with acrocyanosis�Heart rate may be irregular with crying

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Respiration - range 30 to 60 breaths per minute

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Common variations

• Bilateral bronchial breath sounds�Moist breath sounds may be present shortly after birth

Blood pressure - not done routinely

Factors to consider

• Varies with change in activity level�Appropriate cuff size important for accurate reading�Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities

General Measurements

• Head circumference –

33 to 35.5 cm

• Measured at top of eyebrow to widest part of occiput

Expected findings

• Head should be 2 to 3 cm larger than the chest
• Chest Circumference 30.5 to 33 cm
• Measured at nipple line

Head and chest circumference may be equal for the first 24 to 48 hours of life, why??

Common variations

Molding of head may result in a lower head circumference measurement

• Weight range - 2500 - 4000 gms
• Length range - 48 to 53 cm
• Measured on supine, Crown-to-heel

head at midline, full extension of the knees

General Appearance

• Well-flexed, full range of motion, spontaneous movement

COMON VARIATION

• Legs extended with frank breech

• Weight range - 2500 - 4000 gms
• Length range - 48 to 53 cm
• Measured on supine, Crown-to-heel

head at midline, full extension of the knees

Skin

Expected findings

• Skin reddish in color, smooth and puffy at birth

• At 24 - 36 hours of age, skin flaky, dry and pink in color�Edema around eyes, feet, and genitals�
• Vernix caseosa �a 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 drying�without any sign of infection

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Common variations

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• Acrocyanosis - result of sluggish peripheral circulation

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• Mongolian spots in infants of African-American descent

Mottling

Physiologic jaundice

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Physiologic jaundice

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Milia�enlarged sebaceous glands found on nose, chin, cheeks, and forehead; regress in several days to a week or two. �

• Erythema toxicum

(“newborn rash”)—pink to red papular rash appearing on trunk and diaper areas; regresses within 48 hours.

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Head

Expected findings

• Anterior fontanel diamond shaped

3- 4cm

Posterior fontanel triangular 0.5 - 1 cm�

Fontanels soft, firm and flat�Sutures palpable with small separation between each

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Common variations

Caput succedaneum

A newborn’s scalp often is swollen from edema and bruising over the occipitoparietal region

Molding of fontanels and suture spaces

infant’s cranial bones may overlap at the sutures to a certain degree, as a results from passage of the head through the birth canal and disappears within 2 days. It is not seen in babies born by cesarean section.

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Signs of potential distress or deviations from normal findings

• Fontanels that are bulging or depressed�Hydrocephalus�Cephalhematoma

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localized swelling involving the scalp.

Eyes

Expected findings

Gray or blue eye color�No tears�Fixation at times - with ability to follow objects to midline Red reflex�Blink reflex�Distinct eyebrows�Cornea bright and shiny�Pupils equal and reactive to light

Uncoordinated movements

• Opaque lenses�Absence of Red Reflex�
• "Doll's eyes" beyond 10 days of age�this Reflex absent�
• Subconjunctival hemorrhage

Nose�

Expected findings

• Nostrils patent bilaterally�Obligate nose breathers�No nasal discharge
• Have a sneeze reflex with or without stimulation.

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Mouth and Throat

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Expected findings

• Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.

• Palate high arched
• . Uvula midline�. Minimal or absent .salivation�. Tongue moves freely and does not protrude�
• . bilateral cheeks�. Sucking reflex�. Rooting reflex�. Gag reflex�

Signs of potential

deviations from expected findings

• Cleft lip or cleft palate�Lip movement asymmetrical�Reflexes absent or incomplete�Protruding tongue�Candida Albicans

• Precocious teeth

Neck�

Expected findings

• Short and thick�Turns easily side to side�Clavicles intact�Tonic neck reflex present�

Chest

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Expected findings

• Evident xiphoid process�Equal anteroposterior and lateral diameter �Bilateral synchronous chest movement�Symmetrical nipples
• Breath without effort or evident cyanosis

Common variations

• "Witch's milk"�
• Enlarged breasts�
• Accessory nipples

Abdomen�

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Expected findings

Dome-shaped abdomen

Abdominal respirations

Soft to palpation�Well formed umbilical cord�Three vessels in cord�(1 vain & 2 arteries )

Cord dry at base�Liver palpable 2 - 3 cm below right costal margin�Bilaterally equal femoral pulses�Bowel sounds auscultated within two hours of birth�Voiding within 24 hours of birth�Meconium within 24 - 48 hours of birth

Female Genitalia

Expected findings

• Edematous labia and clitoris�Labia majora are larger and surrounding labia minora�Vernix between labia

urination within 24 hrs

Male Genitalia

Expected findings

• Urinary meatus at tip of glans penis�Palpable testes in scrotum� scrotum is large, edematous.

urination within 24 hrs

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Back and Rectum

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Expected findings

• Intact spine without masses or openings
• Patent anal opening
• “Anal reflex" present
• Passage of meconium within 48 hrs

Extremities

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Expected findings

• Maintains posture of flexion�Equal and bilateral movement and tone�Full range of motion all joints �Ten fingers and ten toes�Negative hip click�Grasp reflex present

�Dislocation of hip

• 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
• This tow test are just performed in neonatal period, after age of six weeks these are unpredictable because of increase muscle tone

Neuromuscular System

Expected findings

• Maintains position of flexion�Able to turn head side to side when prone
• Able to hold head in horizontal line with back when held prone
• Head lag while sitting, with ability to hold head momentarily erect

Reflexs

• Moro Reflex: Sudden change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers ,with index finger and thumb forming c shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry; disappears after age 3-4months .
• Palmer grasp: touching palm of hand near base of digits cause flexion of hands, lessens after age 3 months.
• planter grasp: touching feet near base of digits cause flexion to toes, lessens by 8months age

Palmer grasp reflex

• Babniski reflex: stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
• Rooting reflex: touching the cheek along side of mouth causes infant to turn head toward that side and begin to suck ;disappear at age 3-4 months, may persist for up to 12 months.

Babinski's Sign in

a healthy newborn

Moro Reflex

• Sucking reflex: infant begins sucking movement of circumpolar area in response to stimulation ; persists though –out infancy , even without stimulation ,such as during sleep.
• Tonic neck reflex: when infant head is turn to one side, arm and leg extend on that side, and opposite arm and leg flex , disappears by age 3-4 months

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 while holding their breath. This is why some families believe in swim training for very little babies. It is not recommended for you to test this reflex at home for obvious safety reasons.
• Doll’s eye reflex : as a head of infant moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation developed if persists , indicate neurological damage.

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Dance or step reflex: if infant is held so that the sole of foot touch a hard surface there is flexion and extension of the leg stimulating walking. 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 4 months

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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