Neonate Physical Assessment Flashcards
1st A in APGAR and scoring
Appearance
0 = cyanosis or pallor over entire body
1 = normal except for extremities
2 = entire body normal
P in APGAR and scoring
Pulse
0 = absent
1 = less then 100 bpm
2 = greater then 100 bpm
G in APGAR and scoring
Grimace (irritability)
0 = unresponsive
1 = grimace
2 = cries, sneezes, coughed, and recoils
2nd A in APGAR and scoring
Activity (muscle tone)
0 = absent
1 = flex limbs
2 = infant moves freely
R in APGAR and scoring
Respiration
0 = absent
1 = bradypnea, dyspnea
2 = good breathing and crying
head vs chest circumference
the head is usually 2cm greater then chest circumference
normal neonate RR
30-60 per min
normal HR in neonate
120 - 160 while awake; 100 bpm asleep; 180 bpm while crying
normal chest circumference
30-36cm
normal head circumference
32-38 cm
normal length
45-55cm
what is the PMI
point of maximal intensity (heart sound location ) - neonate its between the 4th intercostal space and the midclavicalar line
how to properly fit a blood cuff on a neonate
25% wide then the width of the infants arm in the area it will be applied
hypertension in neonates
SBP greater then 90, DBP greater then 50; these values are lower in preterm
how should MAP correlate with preterm infants
MAP should match the gestational age of the infant; example 28 week preterm should have a MAP of 28
if the S1 is louder then normal it means…and name 3 causes
cardiac blood flow is higher; conditions that cause this are penitent ductus arteriosus, ventricular septal defects, and tetralogy of fallot
if S1 is softer or quieter than normal…and what are 2 causes?
lowered cardiac output; CHF and myocarditis
what is the silverman-anderson index
used to elevate respiratory status; a score of 0 indicates normal findings and higher scores indicate resp distress
when are bowel sounds usually present in a newborn?
30-60 mins after birth
stomach capacity of a newborn
50-60ml
stool colors for breastfeed neonates
yellow gold and mushy
stools in formula fed neonates
pale yellow and pasty
nervous flammeus birth mark
port win stain - unraised red purple lesion caused by capillaries below the epidermis
nevus vasculosus birthmark
strawberry mark - capillary hemangioma, raised, dark red lesion
acrocyanosis
slight cyanosis in hands and feet during the 2-6 hours after birth especially if chilled
mottling in neonates
common for hrs to weeks after birth and may be related to long periods of apnea/chilling
harlequin sign
deep color on one side of body for 1-20 mins usually
erythema toxicum
perifollicular lesions, 1-3 mm white or yellow with pustule appears suddenly all over body mins palms and soles; usually goes away on own, cause unknown
military
small raised white spots on face from exposed sebaceous glands; transient
vernix
thick, waxy substance that is secreted by the sebaceous glands and mixed with sloughed off skin; starts being produced at 20 weeks, thick at 25-40wks gestation and then 42-44wks no vernix
describe 24-26wk gestation skin
translucent, red, many visible blood vessels and scant vernix
describe skin at 35-40wk gestation
deep cracks, no visible blood vessels, and thick vernix
describe skin at 42-44weeks gestation
dry, peeling skin, no vernix, and loss of subcutaneous fat
neonatal feet should be….
flat
neonatal hips should abduct to….
greater then 60 degrees
palmer grasping
strokes the infants palm, infant responds by grasping the finger; strong in preterm infants and then fades; a sense indicates CNS deficit or muscle injury
sucking reflex deficiency
premature infants may not have it because it develops around 32 weeks; absent may indicate CNS deficient or depression
moro reflex
startle reflex; make a loud noise or give the infant a gentle jolt = extends arms, legs, and neck and then pulls arms and legs back, may cry; disappears at 5-6 months, asymmetric indicates peripheral nerve injury, fix of long bones, clavicle or skull
tonic neck
fencing - with infants supine, turn head to one side = extremities flex on opposite side should and extend on same side
how long do infants have babinski reflex?
up to 2 years old, after that toes flex
stepping reflex
newborn is held upright and with the feet touching a horizontal surface, the contact should make the infant lift one foot and then the other, giving the appearance of walking; promotes muscle development and usually disappears in 4 months; if missing, may have motor nerve defect or other neurological abnormalities
pull to sit test
truncal tone test
what is craniotabes?
area of soften skull found in 30% of all newborns (more common in preterm infants)
caput succedaneum
collection of fluid beneath the skin but is superficial to the periosteum, swelling crosses suture lines; caused heading pressing against the suture lines during labor and by vacuum assisted deliveries
cephalohemotoma
blood vessels between skull and periosteum rupture causing a subperiostel collection of blood; appears several hours after birth; !!!does not cross suture lines!!! if large can cause complications such as anemia and hypovolemia - blood eventually is reabsorbed and may cause jaundice
