NEONATE: Physical Development Assessment Tools

Question 1

Physical Development Assessment Tools (4)

Answer 1

Brief Initial
Gestational Age
Vital signs
Head to toe

Question 2

Brief Initial (5)
Purpose

Answer 2

Purpose: A nurse performs a quick initial assessment to review systems and to observe the neonate for any abnormalities.

• External assessment – skin color, peeling, birthmarks, nail length, foot creases, breast tissue, nasal patency, and meconium staining (may indicate fetal hypoxia).
• Chest – point of maximal impulse location, ease of breathing, auscultation for heart rate and quality of tones and respirations for crackles, wheezes, and equality of bilateral breath sounds.
• Abdomen – rounded abdomen and umbilical cord for one vein and two arteries.
• Neurologic – muscle tone and reflex reaction (Moro’s reflex). Palpate the presence and size of fontanels and sutures, and assess fontanels for fullness or bulge.
• Other observations – inspect for any gross structural malformations.

Question 3

A gestational age assessment
is performed within 2 to 12 hr of birth. Neonatal morbidity and mortality are related to gestational age and birth weight.

Weight
Length
Head circumference
Chest circumference

Answer 3

∆
Neonatal morbidity and mortality are related to gestational age and birth weight. This assessment involves taking measurements of the newborn and the use of the New Ballard Scale which provides an estimation of gestational age and a baseline to assess growth and development.
•
The normal ranges of physical measurements include:

◊ Weight – 5.5 lbs -8.9 lbs

2,500 to 4,000 g. The infant’s weight should be obtained by placing a protective liner on the scale prior to weighing to protect the infant from heat loss. Weigh the infant at the same time daily.

◊ Length – (18 to 22 in)

45 to 55 cm (18 to 22 in). The infant’s length should be measured from the top of the head to the heel of the foot.

◊ Head circumference – (12.6 to 14.5 )

32 to 36.8 cm (12.6 to 14.5 in). The infant’s head circumference is measured at the widest diameter, which is the occipitofrontal at the level of the infant’s eyebrows.

◊ Chest circumference –(12 to 13 in)

30 to 33 cm (12 to 13 in). The infant’s chest circumference is measured at the nipple line and should be 2 to 3 cm less than the head circumference.

Question 4

Vital Signs

Answer 4

Vital signs are normally checked in the following sequence:

1) respirations: increases from 30 to 60/min with short periods of apnea (less than 15 sec)
2) heart rate: 100 to 160 beats/min
3) blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic
4) temperature. 36.5 to 37.2° C (97.7 to 98.9° F) axillary.

If the neonate becomes chilled (cold stress), oxygen demands can increase and acidosis can occur.

The nurse should observe the respiratory rate first before the infant becomes active or agitated with the stethoscope, thermometer, and/or the blood pressure cuff.