Chapter 20: Normal Newborn Assessment

Question 1

normal newborn V/S

Answer 1

• Pulse: 110-160
• respirations: 30-60 (abdominal breathers, nose breathers)
• temp: 36.5-37.5 C (97.7-99.4 F)
• BP: 65-95/30-60
  
  • if infant is crying, it will inc BP by 20 mmHg

Question 2

how often to assess infants respirations at birth?

what components of the hx are important to assessing respirations?

Answer 2

• assess at least Q30 min for first 2 hour or until stable
• find out about GBS status, narcotics, and SSRIs in mom’s hx

Question 3

acrocyanosis

Answer 3

• peripheral cyanosis involving only the extremities
• normal during first day and if infant becomes cold
  
  • occurs due to poor perfusion of blood to periphery

Question 4

choanal atresia

Answer 4

• blockage or narrowing of a nasal passage
  
  • must assess b/c infants are nose breathers
  • if bilateral choanal atresia, can cause RDS and require surgery

Question 5

pallor or ruddy color to skin

Answer 5

• pallor: can indicate slight hypoxia or anemia
  
  • get an H&H
• ruddy color: can indicate polycythemia, excessive RBCs
  
  • confirmed by Hct over 65%
  • inc risk for jaundice

Question 6

what is normal cap refill in the newborn?

Answer 6

• 3-4 sec
  
  • assessed on chest, abdomen, or extremities

Question 7

assessment of thermoregulation

Answer 7

• take temp soon after birth
  
  • assess Q30 min until stable for 2 hrs after birth
• most commonly taken axillary

Question 8

size and shape of the newborn head

Answer 8

• head and neck make up 1/4 of the body surface
• C/S: round head
• vaginal: molding present
  
  • molding: caused by overriding of of the cranial bones at the sutures
    
    • usually resolved in a few days
• breech: may be flattened on top
• fontanels:
  
  • anterior: diamond shaped, closes by 18 mos
  • posterior: triangular, closes by 2 mos
    
    • should be soft and flat
    • depressed–>dehydration
    • bulging–>inc intracranial pressure

Question 9

caput succedaneum vs. cephalohematoma

Answer 9

• caput succedaneum: area of localized edema that occurs due to pressure against the mother’s cervix
  
  • crosses suture lines
  • disappears in 12-48 hours
  • may also occur w/ a vacuum extractor
• cephalohematoma: bleeding b/w periosteum and skull is result of pressure
  
  • may not be present at birth, but occurs w/in 24-48 hours
    
    • may take 2-3 mos to resolve
  • does not cross suture lines

Question 10

assessment of the umbilical cord

Answer 10

• should have 2 arteries and 1 vein
• assess for Wharton’s jelly
• yeloow brown or green tinge may indicate meconium was released in utero

Question 11

assessment of extremities

Answer 11

• should have equal but random movements
  
  • extremities should remain sharply flexed and resist extension
• assessment of the hands and feet:
  
  • creases:
    
    • normal on hand: 2 long transverse creases
    • simian crease: common w/ Down syndrome
    • feet: further in gestation, the further down creases will go
  • assess for club foot
    
    • if foot cannot be turned to midline

Question 12

assessment of the hips

Answer 12

• examine for hip dysplasia
• use Barlow and Ortolani tests to check for hip instability
  
  • both legs should abduct equally
  • abnormal: hip clunks
• legs should be equal in length and thigh and gluteal creases should be symmetric

Question 13

measurements of length, head, and chest

Answer 13

• length: from top of head to heel of outstretched leg
  
  • average is 48-53 cm (19-21 in)
• head circumference: 32-38 cm (13-15 in)
  
  • may be affected by molding
• chest circumference: 2-3 cm smaller than the head
  
  • 30-36 cm (12-14 in)

Question 14

reflexes

Answer 14

• indicate health of the CNS
• nurse should note the strength and symmetry of the responses

Question 15

sensory assessment: ears and eyes

Answer 15

• ears:
  
  • line from outer canthus should be even with area where upper part of ear attaches
  • should be vertical
  • stiffness of cartilage and degree of incurving help determine gestational age
• eyes: symmetrical and same size
  
  • sclera should be white or bluish white
  • transient strabismus is common during first 3-4 days
  • should respond to visual stimuli by blinking

Question 16

movement assessment of newborn

Answer 16

• assess for tremors or jitteriness
  
  • tremors often indicate hypoglycemia
  • seizures indicate CNS or metabolic abnormality
    
    • if flexed, tremors will stop, but seizure will not
• cries should NOT be shrill, high pitched, hoarse, or catlike
• should respond to holding and are quiet and content when needs are met
  
  • rocking motions are often effective to quiet an infant
  • normal: nestle body to the person holding them
    
    • CNS injury if stiffen body, pull away, arch back

Question 17

Babinski reflex

Answer 17

• test by stroking lateral sole of foot from heel to across base
• expected: toes flare with dorsiflexion of big toe
• disappears: 8-9 mos

Question 18

Gallant reflex

Answer 18

• w/ infant prone, lightly stroke along side of vertebral column
• response: entire trunk flexes toward side stimulated
• disappears at 4 mos

Question 19

Grasp reflex

Answer 19

• press finger against base of infant’s fingers or toes
• response: fingers curl tightly, toes curl forward
• disappear at 2-3 mos for palmar; 8-9 mos for plantar

Question 20

Moro reflex

Answer 20

• let infant’s head drop back approx 30 deg
• reponse: sharp extension and abduction of arms followed by flexion and adductino to embrace position
• disappear 5-6 mos

Question 21

rooting reflex

Answer 21

• touch or stroke from side of mouth toward cheek
• response: turn head to side touched
• disappears at 3-4 mos

Question 22

stepping reflex

Answer 22

• hold infant so feet touch solid surface
• response: infant lifts alternate feet as if walking
• disappears 3-4 mos

Question 23

sucking reflex

Answer 23

• place finger in mouth and rub palate
• response: infant begins to suck
• disappears at 1 yr

Question 24

swallowing reflex

Answer 24

• place fluid on back of tongue
• response: infant swallows fluid
• present throughout life

Question 25

tonic neck reflex/fencing

Answer 25

• gently turn head to one side while infant is supine
• response: infant extends extremities on side to which head is turned, with flexion on opposite side
• may be weak at birth, but disappears at 4 mos

Question 26

female genitalia

Answer 26

• labia majora are large and cover clitoris/labia minora
• labia may be darker due to exposure to hormones
• edema of labia and white vaginal discharge are normal
• pseudomenstruation is normal
• urinary meatus and vagina should be present

Question 27

male genitalia

Answer 27

• scrotum should be pendulous and may be dark brown from hormones
  
  • rugae are deep and cover scrotum
• assess for testes: should be small, round, moveable
• urinary meatus should be at tip of glans
  
  • underside: hypospadias
  • upper side: epispadias

Question 28

vernix

Answer 28

• thick, white substance that provides a protective covering for fetal skin in utero
• if full term, there will be little left on the body except in creases
• if yellow tinged, elevated bilirubin
• if green tinged, meconium

Question 29

lanugo

Answer 29

• fine, soft hair that covers the fetus during intrauterine life
  
  • as fetus nears term, lanugo becomes thinner
• helps determine gestational age

Question 30

milia

Answer 30

• white cysts tat disappear without treatment
• occur over the forehead, nose, cheeks, chin

Question 31

erythema toxicum

Answer 31

• red blotchy areas with white or yellow papules or vesicles
• commonly called newborn rash and resembles acne
• appears during first 24-48 hours
• common over face, back, shoulders, and chest

Question 32

breasts of the newborn

Answer 32

• note placement of nipples and supernumary nupples
• occasionally may be engorged or secrete white fluid due to maternal hormones

Question 33

hair and nails in the newborns

Answer 33

• full term: silky and soft
• preterm: wooly or fuzzy
• nails:
  
  • postterm: very long nails
  • green stain: meconium, fetal distress

Question 34

Mongolian spots

Answer 34

• bluish gray marks that resemble bruises
• occur most often in newborns with darker skin tones
• disappear after first few years

Question 35

stork bites (nevus simplex)

Answer 35

• also called telangiectactic nevus
• flat, pink discoloration from dilated capillaries on eyelids, bridge of nose, or nape of neck
• blanches when area is pressed and more prominent when crying
• lesions disappear by 2 yo

Question 36

nevus flammeus

Answer 36

• AKA port wine stain
• permanent, flat, pink to dark red mark
• does not blanch
• can be lightened by laser therapy

Question 37

nevus vasculosus

Answer 37

• AKA strawberry hemangioma
• consists of enlarged capillaries on the outer layers of skin
• dark red and raised with rough surface
• regresses over time

Question 38

cafe au lait spots

Answer 38

• permanent, light brown areas
• 6 or more that are larger than 0.5 cm are assoc with neurofibromatosis

Question 39

assessment tools for gestational age

Answer 39

• New Ballard Score: used to assess gestational age based on neuromuscular and physical characteristics
  
  • best if done w/in 12 hours of birth
  • takes into account: posture, square window, arm recoril, popliteal angle, scarf sign, heel to ear and physical characteristics

Question 40

square window

Answer 40

• elicited by flexing the hand at the wrist until the palm is as flat against the forearm as possible
  
  • angle b/w palm and forearm is measured
  • if only bends 90 deg–score is zero
    
    • then age is less than 32 weeks
  • more mature the neonate, the smaller the angle due to the maternal hormones at the end of pregnancy

Question 41

popliteal angle

Answer 41

• used to assess gestational age
• to measure, the newborn’s leg is folded against thigh with the thigh on the abdomen
  
  • then, with thigh flexed on abdomen, straighten lower leg until meet resistance
    
    • 0 score if leg can be fully extended: more preterm
    • if less than 90: more full term

Question 42

scarf sign

Answer 42

• used to assess gestational age
• nurse grasps the infant’s hand and brings arm across body to the opposite side, keeping shoulder flat on bed
  
  • position of elbow in relation to center of body is noted
  • if arm wraps across body easily, then 0–>preterm
  • if elbow fails to reach midline–>full term

Question 43

physical characterisitcs assessed for gestational age

Answer 43

• skin:
  
  • color
  • visibility of veins
  • peeling and cracking: more so in full term
  • vernix
• lanugo
• plantar surface
  
  • more creases as closer to term
• breasts
• eyes and ears
  
  • ears: more cartilage, stiffer as closer to term
• genitals