The Newborn Exam Lecture Powerpoint

Question 1

APGAR score

Answer 1

2 scores done at 1 and 5 minutes of birth to assess the integrity of the cardiopulmonary system based on appearance, pulse, grimace (reflex irritability to suctioning), activity (muscle tone), and respiratory effort rating each on a scale of 0-2 (appearance pale or blue, body pink extremities blue, or pink all over, pulse absent, below 100, or over 100, grimace none, weak, or strong, activity limp, some flexion, or spontaneous movement, and respiratory effort absent, hypoventilation gasping, or coordinated vigorous cry) with a maximum score being 10 and a score less than 7 indicating the infant at risk

Question 2

Routine newborn care orders (11)

Answer 2

• inject vit k 1mg IM
• erythromycin opthalmic 1cm ointment to both eyes (prophylaxis, required in most states)
• feed early and often (<2 hours) to prevent hypoglycemia
• glucose screening
• vitals
• weight (weight loss is normal but stop losing around day 5 then weight gain, want to be at birth weight by 2 weeks of age)
• routine hearing screening
• routine metabolic/genetic screening
• circumcision
• bilirubin measures 8-12 hours and at discharge
• hep B vaccine and hep B immunoglobin if mom is antigen pos

Question 3

Jaundice/hyperbilirubinemia occurs when total serum bilirbuin is greater than…
Direct vs indirect is reabsorbed and which is excreted in colon?

Answer 3

…5mg/dl

Direct is not reabsorbed, it goes DIRECTLY out the body

Question 4

___hyperbilirubinemia is the most commonly encountered jaundice of the newborn, while ____ hyperbilirubinemia is always pathologic and can indicate a serious underlying disorder

Answer 4

Unconjugated, conjugated

Question 5

Physiologic jaundice

Answer 5

Becomes present on 2nd or 3rd day of life, peaks on 4th then decreases, exaggerated in breastfeeding jaundice but is harmless, typically due to unconjugated bilirubin depositing into skin and surface tissues, if unconjugated builds up it can cross the BBB (conjugated cannot) and this will lead to kernicterus

Question 6

Pathologic jaundice

Answer 6

Jaundice that presents in the first 24 hours or if it increases by more than 5mg/dL per day or is >17 (total), or if the infant is showing signs and symptoms of serious illness, or if it is conjugated hyperbilirubinemia

Question 7

Physical exam of hyperbilirubinemia of the newborn (3)

Answer 7

• appearance (yellow coloration)
• press on skin and look for blanching to reveal tone underneath
• clears from bottom to top of body (can be used as an estimate to look at legs and see if they are clearing to estimate level)

Question 8

High risk hyperbilirubinemia of the newborn treatment options

Answer 8

• phototherapy

- exchange transfusion in severe cases

Question 9

Dubowitz clinical assessment

Answer 9

Gestational age assessment based on 10 neurologic signs and 11 external criteria

Question 10

Neuromuscular maturity assessments (dubowitz clinical assessment) (6) (there’s 10 idk why we aren’t going thru all of them)

Answer 10

• Posture (more flexed the higher score 0-4)
• Square window (wrist flexion -1 to 4)
• arm recoil (flex forearms 5 sec then fully extend then see rxn, more they flex higher score 0-4)
• Popliteal angle (alternating flexed and extended legs and measuring angle 180 -1 to <90 being 5)
• scarf sign (how far can cross elbow, if reaches opposite shoulder then -1 to does not cross proximate axillary line 4)
• Heel to ear (draw baby’s foot as near to head as it will go and grade on diagram)

Question 11

Physical maturity assessments (dubowitz clinical assessment) (7) (technically 11 of them exist)

Answer 11

• Skin (should be sticky, friable, transparent, superficial peeling)
• Lanugo (range from none to abudnant to thinning to bald from least mature to most)
• plantar creases (uhh)
• breast (imperceptible to full areola -1-4)
• eye and ear (lids fused or firm developed with thick cartilage)
• male genital development (testes should have descended)
• female genital development (clitoris should shrink and majora covers clitoris and minora)

Question 12

History questions in the newborn examination (5)

Answer 12

• pregnancy related health issues
• blood types
• medications
• lactation
• prenatal lab values

Question 13

Physical exam of the newborn

Answer 13

• height (length) weight and head circumference
• temp (best is rectal)
• measure other vitals
• skin assessment (color, trauma, color change)

Question 14

Cutis marmorata

Answer 14

Reticulated mottling of skin that symmetrically involves trunk and extremities, harmless and does not need to be treated

Question 15

Harlequin color change

Answer 15

Occurs when a newborn lies on side and sees erythema of the dependent side of the body with simultaneous blanching on the contralateral side, benign and often unnoticed

Question 16

Mongolian spots

Answer 16

Blue or slate gray color skin marks that resemble bruises but are not sensitive to touch, usually fade by school age and do not need treatment - but document so they are not confused with bruising

Question 17

Benign infantile hemiangioma, complications and when does it need referral, treatment (1)

Answer 17

Common 3 stage benign skin lesion that typically requires no treatment, most common complication is ulceration, need further eval for large or segmented, multiple, or those located near sacral spine, midline, or near eye, can be treated with propranolol

Question 18

Nevus complex (macular stain)

Answer 18

Benign ocurring in 40-60% of infants that fades in 1-2 years but can persist with no consequence

Question 19

Erythema toxicum neonatorum (rash of the newborn)

Answer 19

common benign skin condition of newborns in almost 50%, usually between day 3 and 2 weeks of life, appears as small yellow to white papules surrounded by red skin (“flea bitten”), usually on face, chest back, upper arms, and sometimes on thighs but palms and soles are spared, no treatment needed and usually fade or disappear over 2 weeks. If no other signs of infection present, then doesn’t need workup

Question 20

Acne neonatorum (infant acne)

Answer 20

Common in 20% of newborns, most resolves spontaneously without scarring with no treatment needed, in extreme cases can use benzoyl peroxide

Question 21

Seborrheic dermatitis (cradle cap) and treatment options (3)

Answer 21

Very common rash characterized by erythema and greasy scales on the newborn, can affect the face, ears, and neck, usually self limiting but can be treated with white petroleu, ketoconazole shampoo, or hydrocortisone cream

Question 22

Eczema of the newborn and treatment options (3)

Answer 22

Common in infancy and usually resolves by age 2, can be found all over body in dry patches and can be itchy, treat with vaseline, sensitive skin soaps, sometimes steroid creams

Question 23

Diaper dermatitis

Answer 23

Typically caused by candida infection of the newborn (sees satellite lesions) or strep B, can occur if diapers are not being changed resulting in skin breakdown, can treat with antifungal cream or antibiotic

Question 24

Bulging, sunken, early closure of the fontanel on assesment can indicate each of these codnitions

Answer 24

• increased intracranial pressure
• dehydration
• craniosynctosis (early closure)

Question 25

When does the fontanel typically close?

Answer 25

9-15 months of age

Question 26

Caput succedaneum vs cephalohematoma

Answer 26

Depends on space where found, caput succedanoeum crosses suture lines and cephalhematoma does not, both are typically self resolving

Question 27

Red reflex exam on infants and fundoscopic exam on infants

Answer 27

Recommended to always do, not recommended need referral

Question 28

Small conjunctival hemorrhages are common during…

Answer 28

….birth

Question 29

Low set ears on newborn and association

Answer 29

Associated with congenital kidney defects and other chromosome disorders

Question 30

Choanal atresia

Answer 30

Blockage of nasal airways by tissue or bone congenitally, concern because infants require breathing thru nose, if concern can be tested patency with catheter

Question 31

Common conditions of the mouth and pharynx and what they are in the newborn (4)

Answer 31

• tongue tie (ankyloglossia)
• cleft palate
• bifid uvula
• epstein pearls (pinhead, whitish benign self resolving round lesions of heart palate)

Question 32

Torticollis and treatment (1)

Answer 32

Condition in which the head is tilted to one side while chin is rotated to the other shoulder, a hematoma of SCM muscle or birth injury can produce, can be repaired with physical therapy

Question 33

Study of choice in concern for fetal heart malformation

Answer 33

echocardiogram

Question 34

Dextrocardia

Answer 34

Heart oriented to the right side of the body opposed to the left

Question 35

Delay or absence of femoral pulse should raise suspicion of what in the newborn? What test do you order?

Answer 35

Coarctation of the aorta, echocardiogram

Question 36

Umbilical cord stump analysis

Answer 36

Should have 2 umbilical arteries and one vein, presence of only one artery may indicate congenital renal abnormalities

Question 37

Scaphoid abdomen

Answer 37

Abdomen that is not protruberant characteristic of the newborn, indicative of diaphragmatic hernia

Question 38

Umbilical hernia of the newborn

Answer 38

Common herniation that usually closes on its own by 2 years of age, surgical closure can be considered at later age

Question 39

Should the umbilical stump be treated when infected?

Answer 39

Normally just leave it and let it fall off, if infected can use topical antibiotic and rarely systemic

Question 40

Failure of meconium passage in first 24 hours indicates possibility of these 2 pathologies

Answer 40

cystic fibrosis

hirschsprungs disease

Question 41

Barlow and ortolani maneuvers

Answer 41

Downward force while hip is adducted andupward force while hip is abducted listening for a click indicative of hip dysplasia, requires ultrasound to rule out if positive (or if the baby is born in breech position then always)

Question 42

Primitive reflexes (7) and description of them***

Answer 42

1) Rooting reflex - turn head and mouth towards finger stroking cheek laterally
2) sucking reflex - tendency to isntinctivly suck vigorously at anything touching the mouth and swallow it regardless if hungry or not
3) moro reflex - as child is slowly lowered head down their upper limbs abduct (thrown up)
4) grasp reflex - instinctively grasp upon placing any object on palm and cannot voluntarily let go up until a year of age, same with toes
5) placing reflex - pick foot up if held in front of table edge and place it on table
6) asymmetrical tonic neck reflex/fencer reflex - when lying supine turn head 90 degrees they take on a fencing pose
7) walking reflex - when held above ground will place one foot in front of other