Assessment Of The Normal Newborn Flashcards
Vital Signs/ Measurements: Temp
Axillary- 36.5-37.5 C (97.7- 99.5 F)
Vital Signs/ Measurements: apical
120-160
Vital Signs/ Measurements: Respirations
30-60
Vital Signs/ Measurements: weight
Classification of newborns: 2500-4000g (5lb, 8oz-8lb,13oz)
Small for Gestational Age- SGA
Appropriate for Gestational Age- AGA
Large for Gestational Age- LGA
Vital Signs/ Measurements: length
48-53 cm (19-21 inches)
Small for Gestational Age- SGA
Appropriate for Gestational Age- AGA
Large for Gestational Age- LGA
Vital Signs/ Measurements: Head Circumference:
32-38cm (13-15 inches)
Vital Signs/ Measurements: Chest Circumference
30-36cm (12-14 inches)
Apgar Scoring Chart
- 1-3:
- 4-7:
- 8-10:
- it is done twice: once right after birth & five minutes later
- Assess cardiopulmonary
1-3: CPR & likely intubation
4-7: stimulate the baby
8-10: normal- no intervention
Assessing pulses
make sure to compare upper and lower
Mouth
- Check for facial asymmetry
- Check for hard and soft palate intactness, strength of suck
- Look to see if the tongue is not tied due to short frenulum (if frenulum is short it restricts the tongue),
- Baby can distinguish sweet and bitter
- Epstein’s pearls
— keratin containing cysts- feel hard
— Usually disappear without problems - Precocious teeth- neonatal teeth
- Candida albicans (thrush)
- Cleft lip/pallet
Fontanelles
- Assess both anterior and posterior for at least 18 months
- Document if it is flat or bulging
- Anterior fontanelle closes at 12-18 months
- Posterior fontanelle closes at 2-3 months
Head assessment:
Molding:
Caput succedaneum (cone head):
Cephalohematoma
Caput succedaneum (cone head):
- Collection of fluid due to pressure of presenting part against cervix
- crosses suture lines
Cephalohematoma
swelling on one side of the head due to blood collecting
- A rupture between surfaces of cranial bones
- It is a subperiosteal hemorrhage
- Collection of blood between surface of a cranial bone in the peristeal membrane
- Feels loose first, then by 2 - 3 days to several months it is hard.
- May have jaundice as it resolves
Assessing clavicles:
Tx:?
Assess for shoulder dislocation (in large babies)
- Tx: immobilize the arm
Assessing for congenital hip dysplasia
- The greater trochanter* doesn’t fit (you will hear a crunching or clicking sound)
- Unsymmetrical gluteal folds*, abduct, one leg may be longer than the other
Talipes Equinovarus:
Tx:?
Clubfoot
- Where the foot bends inward
to determine the presence of clubfoot, the nurse moves the foot to the midline
- *Resistance indicates true clubfoot
- Tx: casting
Neurological Maturity Posture
- Assess posture for neurological maturity (4 hours after birth)
- flexed posture = term baby
- flaccid posture = preterm
Square window:
Bending the hands/ wrists forward to creat a square
- The more bent the more term
Arm recoil:
Extending baby hands and arms down, then letting go
- baby should flex arms back
Flaccid = preterm
Flexed= term
Popliteal Angle:
Bending leg back to chest to create an angle with leg
- Popliteal angle more square= term baby
- Larger angle= preterm
Scarf sign
Cross body extension
- the maneuver successfully reproduces the patient’s symptoms of pain localized over the AC joint (+)
Heel to ear
- Holding the baby’s foot in one hand, draw the leg towards the ear to see how much resistance there is to the maneuver. The foot should go to about the level of the chest or shoulder, but not all the way to the ear. If the foot can be drawn to the ear then there is hypotonia.
Skin: more dry =
More term
Lanugo
fine hair
Plantar surface
Term baby= more creases
Preterm= less wrinkles
Ear
The pinna should be at your level or above
Low set ears indicate genetic disorders such as down syndrome
Hypospadias
the urethra is not midline
Newborn skin conditions:
Acrocyanosis
Milia
Stork bite (Telangiectatic Nevus)
Erythema toxicum:
Port wine stain (nevus flammeus):
Vernix caseosa:
Mottling Cutis Marmorata:
Mongolian spot:
Harlequin color change:
Acrocyanosis:
Tx:
Not necessarily a bad thing- this is a normal and transient
The peripheral circulation is not stimulation
- TX:
— warm the baby to stimulate circulation
They do not need oxygen
Milia
- Little tiny white dots (Little sebaceous glands that are exposed)
- Normal newborn condition that will subside on its own
Stork bite (Telangiectatic Nevus)
A mark that goes away by 2 years old
Erythema toxicum:
- Follicles that got inflamed- looks like a rash
- Tends to clear within a week
Port wine stain (nevus flammeus):
It is a permanent birthmark (doesn’t go away)
.
Notes:
- Perifollicular eruptions of lesions that are firm one to 3 cm consist of white to yellow papules or pustules with red base. Called flea bites. Peak incident in 24 to 48 hours. Clears five days and causes unknown and there is no treatment.
Vernix caseosa:
- White creamy substance that is on them at birth
- Washed off with first bath
Mottling Cutis Marmorata:
When the baby is cold (Has to do with circulation)
Mongolian spot:
- Common in Asian and African-American babies
- Make sure to document because it looks like a bruise
- They tend to fade away by two years old
Harlequin color change:
transient erythema involving one half of the infant’s body with simultaneous blanching of the other side with a demarcation on the midline.
Reflexes
Moro reflex:
Palmer grasp reflex:
plantar grasp reflex
Babinski reflex:
tonic neck reflex
stepping reflex:
rooting reflex:
Sucking reflex:
Moro reflex:
- Also called the startle flex
it happened when the babies hear - The Moro reflex is the most dramatic reflex. It occurs when the infant’s head and trunk are allowed to drop back 30° when the infant is in a slightly raised position.
- The infants, arms and legs extend and abduct with the fingers, Fanning open and thumbs and forefingers forming a C position
- The arms then returned to their normally flexed state with an embracing motion. The legs may also extend, and then flex.
Palmer grasp reflex:
- The palmar grasp reflex occurs when the infant’s palm is touched near the base of the fingers.
- The hand closes into a tight fist. The grasp reflex may be weak or absent, if the infant has injury to the nerves of the arms.
plantar grasp reflex
The plantar grasp reflex is similar to the Palmar grasp reflex. When the area below the toes is touched, the infants toes curl under the nurses finger.
Babinski reflex:
- The Babinski reflex is elicited by stroking the lateral soul of the infant’s foot from the heel forward and across the ball of the foot. This causes the toes to flare outward and the big toe to dorsiflex.
- Normal to have a positive Babinski
tonic neck reflex
- The tonic neck reflex refers to the position, assumed by newborns when in a supine position
- The infant extend the arm and leg on the side to which the head is turned and flexes the extremities on the other side
- This response is sometimes referred to, as the “fencing reflex” because the infants position is similar to that of a person engaged in a fencing match.
stepping reflex:
The stepping reflex occurs when infants are held up right with their feet touching a solid surface. They lift one foot, and then the other, giving the appearance that they are trying to walk
rooting reflex:
- The rooting reflex is important and breastfeeding and is most often demonstrated when the infant is hungry
When do infants cheek is touched near the mouth the head turned toward the side that has been stroked - This response helps the infant find the nipple for feeding
- The reflex occurs when either side of the mouth is touched
- Touching the cheeks on both sides at the same time confuses the infant
Sucking reflex:
- Very important for breastfeeding
- The sucking reflex is essential to normal life
- When the mouth or pallet is touched by the nipple or a finger, the infant begins to suck
- The sucking reflex is assessed for its presence and strength
- Feeding difficulties may be related to problems in the infants, ability to suck and to coordinate, sucking with swallowing and breathing
