Chapter 20: Normal Newborn Assessment Flashcards
1
Q
normal newborn V/S
A
- 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
2
Q
how often to assess infants respirations at birth?
what components of the hx are important to assessing respirations?
A
- assess at least Q30 min for first 2 hour or until stable
- find out about GBS status, narcotics, and SSRIs in mom’s hx
3
Q
acrocyanosis
A
- peripheral cyanosis involving only the extremities
- normal during first day and if infant becomes cold
- occurs due to poor perfusion of blood to periphery
4
Q
choanal atresia
A
- 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
5
Q
pallor or ruddy color to skin
A
- 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
6
Q
what is normal cap refill in the newborn?
A
- 3-4 sec
- assessed on chest, abdomen, or extremities
7
Q
assessment of thermoregulation
A
- take temp soon after birth
- assess Q30 min until stable for 2 hrs after birth
- most commonly taken axillary
8
Q
size and shape of the newborn head
A
- 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
- molding: caused by overriding of of the cranial bones at the sutures
- 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
9
Q
caput succedaneum vs. cephalohematoma
A
- 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
- may not be present at birth, but occurs w/in 24-48 hours
10
Q
assessment of the umbilical cord
A
- should have 2 arteries and 1 vein
- assess for Wharton’s jelly
- yeloow brown or green tinge may indicate meconium was released in utero
11
Q
assessment of extremities
A
- 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
- creases:
12
Q
assessment of the hips
A
- 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
13
Q
measurements of length, head, and chest
A
- 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)
14
Q
reflexes
A
- indicate health of the CNS
- nurse should note the strength and symmetry of the responses
15
Q
sensory assessment: ears and eyes
A
- 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
16
Q
movement assessment of newborn
A
- 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
17
Q
Babinski reflex
A
- test by stroking lateral sole of foot from heel to across base
- expected: toes flare with dorsiflexion of big toe
- disappears: 8-9 mos
18
Q
Gallant reflex
A
- w/ infant prone, lightly stroke along side of vertebral column
- response: entire trunk flexes toward side stimulated
- disappears at 4 mos
19
Q
Grasp reflex
A
- 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
20
Q
Moro reflex
A
- 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
21
Q
rooting reflex
A
- touch or stroke from side of mouth toward cheek
- response: turn head to side touched
- disappears at 3-4 mos
22
Q
stepping reflex
A
- hold infant so feet touch solid surface
- response: infant lifts alternate feet as if walking
- disappears 3-4 mos
23
Q
sucking reflex
A
- place finger in mouth and rub palate
- response: infant begins to suck
- disappears at 1 yr
24
Q
swallowing reflex
A
- place fluid on back of tongue
- response: infant swallows fluid
- present throughout life
25
tonic neck reflex/fencing
* 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
26
female genitalia
* 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
27
male genitalia
* 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
28
vernix
* 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
29
lanugo
* fine, soft hair that covers the fetus during intrauterine life
* as fetus nears term, lanugo becomes thinner
* helps determine gestational age
30
milia
* white cysts tat disappear without treatment
* occur over the forehead, nose, cheeks, chin
31
erythema toxicum
* 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
32
breasts of the newborn
* note placement of nipples and supernumary nupples
* occasionally may be engorged or secrete white fluid due to maternal hormones
33
hair and nails in the newborns
* full term: silky and soft
* preterm: wooly or fuzzy
* nails:
* postterm: very long nails
* green stain: meconium, fetal distress
34
Mongolian spots
* bluish gray marks that resemble bruises
* occur most often in newborns with darker skin tones
* disappear after first few years
35
stork bites (nevus simplex)
* 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
36
nevus flammeus
* AKA port wine stain
* permanent, flat, pink to dark red mark
* does not blanch
* can be lightened by laser therapy
37
nevus vasculosus
* AKA strawberry hemangioma
* consists of enlarged capillaries on the outer layers of skin
* dark red and raised with rough surface
* regresses over time
38
cafe au lait spots
* permanent, light brown areas
* 6 or more that are larger than 0.5 cm are assoc with neurofibromatosis
39
assessment tools for gestational age
* 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
40
square window
* 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
41
popliteal angle
* 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
42
scarf sign
* 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
43
physical characterisitcs assessed for gestational age
* 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
