The newborn exam Flashcards
1
Q
When will pediatric or neonatal provider attend a birth?
A
- if there is a greater chance that the infant will need resuscitation
- c-sections
- mult births
- premature births
- fetal distress
- high risk pregnancy
2
Q
What should you make sure immediately after the delivery?
A
- airway cleared of secretions
- if baby not in distress may be place on mother and allowed to nurse
- still dried and covered to keep warm
- if in distress or after mother has had baby, infant is assessed
- APGAR scores are obtained
3
Q
Temp regulation in newborn?
A
- regulation isn’t well developed
- sensitive to excess heat loss (hypothermia) and heat retention (hyperthermia)
- temp is monitored close after delivery
- immediately after birth:
infant is dried and radiant heat is provided - also when infant is undressed for physical exam
4
Q
APGAR assess what?
A
- heart rate
- respiratory effort
- muscle tone
- reflex irritability
- skin color
- obtained at 1 and 5 minutes, range 0-10, 7-10= no vigorous resuscitation reqd, stable infant, 4-6 requires stimulation and O2, and 0-3 reqrs assisted ventilation and possible cardiopulmonary support
5
Q
Newborn prophylaxis?
A
- US: std of care for following routine procedures to be performed after birth to prevent serious disorders:
- prophylactic eye care to prevent neonatal gonococcal ophthalmia (erythromycin)
- admin of Vit K1 to prevent vitamin K deficient bleeding (VKDB)
- Hep B vaccination
- umbilical cord care to prevent infection (aseptic clamping/cutting dry cord care)
- monitoring for hyperbilirubinemia and hypoglycemia
6
Q
Routine screening of newborn?
A
- hearing loss
- metabolic and genetic disorders: phenylketonuria, congenital hypothyroidism, galactosemia, and hemoglobinopathies
- and congenitally acquired infectious disorders
- pulse ox to screen for critical congenital heart disease (CCHD)
7
Q
Newborn exam?
A
- can occur immediately or within 24 hrs of birth
- usually done in nursery/in infant bed at mother’s side
- use warming light
- infant completely unclothed
- may use pacifier to quiet crying infant
- look for subtleties:
watch for baby being startled with noise (probably hear), Blinks with bright lights (can see), urinates on you (urethra is patent), defecates (anus is patent), infants response to being examined is a gross neuro exam: crying, moving, fussing,
-jitteriness can be sign of low sugars, seizures, and infections - nasal flaring: respiratory distress
8
Q
General impression of newborn?
A
distress? color? -normal hemoglobin - 16-17 g/dL, ruddy -plethoric in polycythemia ( suspect maternal diabetes) - pallor with anemia or poor perfusion - cyanosis heart/lung disease - tone? normal: flexor tone greater than extensor tone
9
Q
Growth transition of newborn?
A
- fetal growth acclerates in 3rd trimester
- after birth it is normal for term infant to lose wt in first few postnatal days (5-10%). Predominantly due to loss of extracellular water, and inadequate nutrional intake
- by the time the infant is 2 weeks old - it should be back to or above birth wt as feeding improves
10
Q
Measurements of newborn?
A
- wt
- length
- head circumference
- chest circumference
- plot on growth chart to check % and see if parameters are in same range
11
Q
Diff sizes for gestational age?
A
- SGA
- IUGR: symmetric or asymmetric (most common)
- avg for gestational age (AGA)
- large for gestational age (LGA) - macrosomia
12
Q
Etiologies of SGA infants?
A
- congenital infections
- chromosomal defects
- cell toxins (ETOH, narcotics)
- maternal malnutrition
- mult gestations
- pre-eclampsia - asymmetric
- placental abnormalities
- maternal use of tobacco
13
Q
Etiologies of LGA infants?
A
- maternal diabetes
- hydrops fetalis
- genetic predisposition
- male fetus
- post-date gestation
- multiparity
14
Q
Sin exam main pts?
A
- inspect skin for color, lesions, and rashes. Color in dark skinned infants best assessed in oral region and nail beds. Newborn’s skin is thinner than normal, blood vessels can be seen. The more premature, the more can be seen
15
Q
What is Cutis Marmorata?
A
- mottled appearance that will disappear over time
16
Q
What is Vernix Caseosa?
A
- white to yellow waxy covering in newborns, most abundant in creases and flexor surfaces
17
Q
What is lanugo?
A
- downy hair covering the body, more common with prematurity
18
Q
What is Erythema toxicum?
A
- benign rash characterized by fleeting erythematous papules and pustules filled with eosinophils. Usually predominates on face and chest.
- appears 1-14 days after birth and disappears over several days to weeks
19
Q
What is Nevus Flames, Vascular Nevi, Salmon patches?
A
- “stork bites”: when on back of neck
- “crow’s nests”: when above the eyes
- usually benign flat red markings on upper eyelids, in the area above the nose sometimes extending to the forehead, and/or on the back of the neck (may change in intensity with crying)
20
Q
Port-wine stain?
A
- in the nevus flameus family but are permanent discolorations of the skin
- on occasion are assoc with arteriovenous malformations in other organs
21
Q
Sebaceous gland hyperplasia?
A
-small yellow papules that are often seen over nose and cheek, disappear spontaneously
22
Q
Milia?
A
- similar to sebaceous gland hyperplasia but white papules and smaller, again they disappear w/o tx within few weeks
23
Q
What is acne neonatorum?
A
- acne appearance likely from maternal hormonal influence, may take several months to disappear
24
Q
What are mongolian spots?
A
- bluish black macular lesions over lumbrosacral area. Seen in most native American, black and Asian infants. This isn’t a bruise
25
Q
Strawberry or capillary hemangiomas?
A
- elevated collections of capillaries, variable appearance
- grow for 3-7 months, stabilize then at about 1 year begin to involute, pt usually w/o scar or blemish by 5 years of age
- leave alone unless on eyelid in which consult ophthalmologist reqd
26
Q
Cavernous Hemangioma?
A
- much less common than strawberry hemangiomas and have less predictable course. This is a collection of larger blood vessels, usually much larger than strawberry hemangiomas and bluish in color.
- when very large can be assoc with thrombocytopenia
- often, they mature and then disappear
- sometimes requires steroids or radiation tx in extreme cases
27
Q
Jaundice?
A
- yellow staining of body tissues and fluids, as result of excessive levels of bilirubin in bloodstream
- blanch the skin with slide if unsure, area you pressed wil remain yellow b/f skin color returns if jaundiced
- physiologic jaundice of newborn is normal, however, this doesn’t usually appear in first 24 hrs
28
Q
Head exam of newborn – circumference?
A
- meausure head circumference at largest possible diameter (parietal bones, above ears) and compare with stds (should be within 2 SDs of mean for gestational age), normal= 34-35 cm
- increased head circumference greater than 2 SDs may indicate hydrocephalus
- compare with chest circumference - in full term infants - chest circumference should be 1-2.5 cm smaller than head, if not corresponding with guidelines, consult with pediatric neurologist is advisable
29
Q
Head exam of newborn - fontanelles?
A
- palpate anterior and posterior fontanelles
- check for molding and forceps marks (if used):
newborn skull malleable for passage through birth canal, may not be round (if it is - C-section) - anterior fontanelle should be larger - should be flat, usually closes by 18-24 months of age
- posterior fontanelle is smaller, generally closes by 6 weeks of age
30
Q
Head exam - hydrocephalus? clinical features?
A
- increased volume of CSF usually due to obstruction of CSF into subarachnoid space
- clinical features: macrocephaly, an excessive rate of head growth
- irirtability
- vomiting
- loss of appetite
- impaired upgaze
- impaired EOMs
- hypertonia and hyperreflexia
- need ped neuro consult
- tx usually consists of ventriculoperitoneal shunting
31
Q
Head exam - caput succedaneum?
A
- very common, boggy swelling in subcutaneous tissue which crosses the suture lines. Head compression against cervix impedes venous return, reabsorbs within 1-3 days
32
Q
Head exam - cephalohematoma?
A
- blood collected beloow the periosteum and therefore confined to a single bone, will not cross suture line
- not typically apparent until 24-48 hrs after birth
- almost always parietal bone, usually results from fracture
- often lasts more than 4 weeks
- cephalohematoma in older infant who comes in for routine care should make examiner suspicious of child abuse
33
Q
Head exam - craniosynostosis?
A
- abnorm premature closure of skull sutures
- most common is sagittal suture, which leads to anteroposterior lengthening
- fusion of coronal sutures would lead to lateral lengthening
- to detect this, palpate sutures and see if they move up and down independent of one another
34
Q
Head exam - craniotabes?
A
- ping-pong ball feel of the skull
- usually a benign condition that disappears over time
- if persistent investigate for marasmus, rickets, or syphilis
35
Q
Face exam of newborn?
A
- eyes slanting up may indicate Downs, along with sloping forehead, low set ears with small canals, and short broad hands with single palmar crease
- eyes too large may indicate glaucoma
- eyes that appear too small may indicate FAS, along with wide, flat nasal bridge, lacking groove b/t lip and nose and small jaw
- small chin in Pierre Robin syndrome may predispose infant to respiratory obstruction
36
Q
What may asymmetry of the face while crying indicate?
A
- aortic valve abnormalities, consult with ped cardiologist warranted
- may also be facial nerve palsy secondary to pressure on facial nerve during birth process (usually appreciated even when babay isn’t crying and is temporary)
37
Q
Impt parts of newborn eye exam?
A
- positioning and symmetry
- trauma
- reflex eye opening present
- cornea clear
- fundoscopic: red reflex
- erythromycin ointment is applied to eyes routinely
38
Q
Eye exam: sclera and conjunctivae findings?
A
- examine sclera, conjunctivae, corneas, irises, and pupils
- subconjunctival hemorrhage: with trauma from birth process, disappears by end of first week of life
- conjunctivitis: usually not seen in first 24 hrs
- are irises same color?
39
Q
Why are you looking for red reflex with fundoscope?
A
- should see red reflex, if not something is blocking light path such as cataract, or tumor, such as retinoblastoma, need ophtho consult!!
40
Q
Nasal exam?
A
- asymmetry of nares may indicate septal deviation from birth trauma
- patency: if no secretions and unsure if patent, attempt to pass 5 french catheter through nostril
- if not passing: choanal atresia
41
Q
Ear exam?
A
- abnorm of external ear assoc with abnormalities of middle ear (hearing) and renal diseases
- look at EAC for patency, difficult to visualize TMs (more horizontal, pull pinna down)
42
Q
Mouth and throat exam?
A
- palate intact - cleft palate?
- teeth? shouldn’t contain teeth. When teeth present usually removed after consultation with dentist (often attached loosely - could aspirate)
- hard palate masses in midline: epstein pearls (benign)
43
Q
Checking neck and clavicle?
A
- for short neck/webbing (turner’s syndrome)
- check for clavicle fractures - birth trauma
44
Q
Chest exam?
A
- RR: 40
- check nipples: may be some breast tissue from mother’s hormones
- deformities: pectus carinatum (out) and pectus excavatum (in)
- lungs: breathing should be effortless, no nasal flaring or retractions, grunting
- breath sounds should be equal bilaterally
- if abnormality in pattern of breathing: order CXR, unusual to hear rales, rhonchi, and wheezes, even with severe respiratory distress
45
Q
CV exam?
A
- pulse: 120-180
- BP: can check in arm and/or leg
- check radial, femoral, brachial pulses and compare femoral to UE pulses:
if femoral pulses diminished: possible coarctation of aorta - need to check BPs before coarctation and after
- auscultate heart: difficult to appreciate subtle murmurs and they are often transient, if unsure consult ped cardiologist
46
Q
Abdominal exam?
A
- normal appearance: full, protruding and round
- shouldn’t be sunken (scaphoid) nor should it appear tense
- tense abdomen could be associated with intestinal obstruction:
causes could include imperforate anus, Hirschprung disease, and meconium ileus (CF) - or may be assoc with perforated viscus and peritonitis
- scaphoid: concern, could be diaphragmatic hernia, neuro disorder that is leading to poor muscle tone
- inspect umbilical cord: 2 arteries and one vein (if only one artery - assoc with renal malformations)
- Diastasis recti: abdominal separation
- inspect for masses: liver often palpable below right costal margin - an appreciable mass is usually a kidney, resulting from obstrctive lesions of urinary tract
47
Q
Genitalia exam - female?
A
- inspect and palpate:
- labia majora/minora full and puffy
- examine labia/gently separate to inspect clitoris
- influence of maternal hormones may cause withdrawal bleeding rom vagina
48
Q
Genitalia exam - males?
A
- examine for presence of both testes in scrotum, shape and size of penis, foreskin, and location of urethral meatus
- inability to palpate testes could indicate cryptochidism
- hard testis isn’t normal, suspect congenital torsion or tumor, consult with ped urologist
- penis should be straight, if bent ventrally a chordae of the penis may be present and this is assoc with:
hypospadias: condition where urethral meatus is displaced proximally on ventral aspect of penis (don’t circumcise - foreskin used to repair this)
49
Q
Anal exam?
A
- check if imperforate or if fistulas
- anal atresia: imperforate anus is a surgical emergency
50
Q
Musculoskeletal exam?
A
- Count fingers and toes
- clinodactyly is inturning of a finger, usually the 5th, which can be seen with down syndrome
- polydactyly
- syndactyly
- palpate all long bones/clavicales
- hip:
ortolanis and barlows tests/ full abduction - leg length: check for discrepancy
- buttocks: symmetrical creases
51
Q
What is Metatarsus adductus?
A
- forefoot adduction, usually from intrauterine crowding ( this can cause an increased risk for developmental dysplasia of hip)
- the key is whether the foot can be straightened easily, If so no tx necessary, if rigid - requires ortho consult for surgery
52
Q
What is internal tibila torsion?
A
- often seen in conjunction with metarsus adductus, again from intrauterine crowding, usually improves w/o tx over period of months but may take years
53
Q
What is Talipes Equinovarus?
A
- clubfoot: combo of metatarsus adductus, varus deformity, and shortening of Achilles tendon
- tx should begin with newborn in the nursery
54
Q
How do you test for developmental dysplasia of the hips (DDH)?
RFs?
A
- hip abduction should be 180 degrees at birth, and at least 120 degrees in subsequent exams
- buttocks should be symmetrical
- barlow test - dislocate
- ortolani - relocate
- RFs: family hx, breech presentation, and female to male (9:1 ratio)
55
Q
Back exam?
A
- inspect the spine, is it straight?
- any defects, pilonidal sinus?
- in general, any abnormalities of the spine other than pilonidal sinus such as other sinuses,cysts, fatty tumors, or tufts of hair warrants consultation with pediatric neurologist
56
Q
Neuro exam?
A
- babinski sign is positive, normal in infants less than 6 months
- flexor tone greater than extensor tone is normal. When supine and at rest, normal infant is flexed at elbows, hips, and knees
- a floppy baby - extensor greater than flexor reqrs immediate investigation cause can be:
insult to CNS such as intracranial bleeding or infection, congenital disorders of nervous system or muscles, sepsis
57
Q
Brachial plexus palsies?
A
- Erb’s palsy
- one of upper extremities flaccid, usually secondary to difficult delivery with injury to brachial plexus (C5, C6). Often good prognosis but consultation with ped neuro necessary
58
Q
Infant reflexes - moro?
A
- dropping baby down (while supporting head and neck) symmetric abduction and extension
- this is absent on side of brachial plexus palsy
59
Q
- grasp reflex?
A
- grasp reflex: placing index finger in palm of hand will elicit grasp
60
Q
- Plantar reflex?
A
- touching base of toes causes toes to curl downward
61
Q
Stepping reflex?
A
- when placed in standing positon, will elicit stepping reflex
62
Q
Rooting reflex?
A
- stroking cheek will cause infant to turn head towards stimulus and open mouth
63
Q
Is the APGAR score a predictor of neuro development?
A
- NO!
- only guideline for magnitude and duration of resuscitation if necessary
