Basic head To Toe Assessment (newborn)

Question 1

Airway/breathing

Answer 1

Resp rate
Resp effort
Air entry (adequate or adventitious breath sounds)

Question 2

Circulation

Answer 2

-Warmth of skin
-Heart rate (regularity/rhythm/rate)
-Pulses (strength,regularity, central vs peripheral)
-perfusion (cap refill, skin colour (pale/mottled))

Question 3

Neurological

Answer 3

Loc
Mental status (interaction)
Activity, movement, muscle tone
Age appropriate responses

Question 4

Root reflex

Answer 4

When corner of mouth stroked or touched, head will turn, and open mouth in direction of stroking

Question 5

Normal reflexes in newborns

Answer 5

Root reflex
Suck reflex
Moro reflex
Tonic neck reflex
Grasp reflex
Babinski reflex
Step reflex

Question 6

Suck reflex

Answer 6

When roof of mouth is touched baby will beginning to suck

(Begins 32nd week of pregnancy and not fully developed until 36weeks)

Question 7

Moro reflex

Answer 7

(Startle reflex)
Startled baby throws back their head extends arms and legs and cries and pulls arms and legs back in

Last approx 5-6months

Question 8

Tonic neck reflex

Answer 8

Baby’s head is turned to one side the arm on the side stretches out and the opposite bends up at the elbow

Last approx 5-6months

Question 9

Grasp reflex

Answer 9

Stoking the palp of a baby’s hand causes the baby to close their fingers in grasp

(Last 5-6 months)

Question 10

Babinski reflex

Answer 10

When the sole of the foot is firmly stroked the big toe bends back towards the top of the foot and toes fan out

Normal reflex up to 2yrs old

Question 11

Step reflex

Answer 11

Walking or dancing reflex as baby appears to be taking steps when held upright with their feet touching a solid surface

Question 12

GI/GU

Answer 12

Bowel sounds
Appetite
Bowel movements/emesis
Hydration status
-urine output, moist oral mucosa, skin turgor, fontanels

Question 13

Red flags of respiratory distress

Answer 13

Tachypnea

Mechanics of breathing
-retractions, tracheal tug, nasal flaring, head bobbing, grunting on exhalation, prologued expiration phase

Diminished air entry

Change in breath sounds
-stridor
-wheezing

Question 14

Late signs of resp distress

Answer 14

Skin colour changes - dusty or cyanitic

Inaudible air entry

Apnea/irregular resp

Change in LOC / activity

Beadycardia

Question 15

Late signs of resp distress

Answer 15

Skin colour changes (cyanosis or dusky)

Inaudible air entry

Apnea/irregular resp

Changes in activity / LOC

Bradycardia

Question 16

Red flags of cardiovascular collapse

Answer 16

Tachycardia

Alternated perfusion
-decreased pulse quality

Skin
-prolonged cap refill (>2 sec)
-increased core to skin temperature gradient

Brain
-altered LOC /activity
-decreased response, “worried” appearance

Kidneys
-decreased urinary output <1ml/kg/hr

Question 17

Late signs of cardiovascular collapse

Answer 17

Decreased response to pain
Flaccid tone
Hypotension
Bradycardia