Chapter 9 Nursing Assessment of the Newborn(physiologic

adaptation)
-Describe the assessment of the newborns resting posture- on the
back, fexion of the arms (awake and responding)
Apgar (done 1 minute at life and 5 minutes of life) Score of less than
3-requires intervention.
RR-30-60 bpm, emp- !.! (frst temp for newborn done rectally) , !R
""0-"60
"nclu#es#
1 $bservation
2 %nspection
3 &uscultation
4 'alpation ()))))))*
5 'ercussion
$hase 1#
6 +akes place in #eli%er& room ,here -rst phase of reactivit. and
bondin/ is initiated ,ith parents
$hase '#
7 +akes place on a#mission to the ne,born nurser&
8 $ccurs bet,een 1() hours of age ,here a more detailed exam is
performed (/eneral assessment)
$hase 3#
9 +akes place in the roomin/-in settin/ ,ith the parents present
10 $ccurs bet,een 0 hours of a/e until dischar/e
*eneral Appearance#
Newborn resting posture+
1 2lexion3s.mmetr. best observed ,hile bab. restin/
1 +erm ne,born rests ,ith hips abducted
4 2lexed at elbo,
4 5nees fexed
1 Arms a##ucte#
4 2lexed at elbo, ,ith hands in -sts
,pisthotonos 6 extension of the neck ,ith arched back7 associated ,ith
(89 problems
Repetitive blinking or pedaling movements of the lower limbs may
represent seizure activity caused by injury at birth.
Noticeabl& -er.& or -itter& mo%ements ma. indicate excessive
electrical dischar/e from the neurons or a metabolic disorder such as
hypoglycemia, hypocalcemia, or hypoxia
11 (apillar. blood heel stick ma. be done to determine blood /lucose
levels
12 8ormal blood /lucose level is 00 m/3dl or less
Cr& shoul# be strong an# lust&
13 :i/h pitched, shrill cr. is abnormal ; ma. indicate a neurolo/ical
disorder, h.po/l.cemia, or dru/ ,ithdra,al
/ital Signs#
14 9hould be taken ,hen ne,born is quiet or restin/
15 <easured "=-30 min intervals at "
st
, then hourl., and ever. 0-*
hours after the infant is stable (in phase 3care >0 hours of a/e until
dischar/e?).
Normal Ranges# !eart Rate ( newborns HR varies w/ activity )
Apical0 111(121 bpm ) normal
-:eart beat auscultated over the heart (precordial)
re/ion
-9li/htl. belo, left nipple (at the 4
th
intercostal space
and to the left of the midclavicular line)
@Aisten for 1 full min for accurac..
3ra#&car#ia 6 hr less than 111 beats per min
ach&car#ia 6 hr greater than 121 beats per min
Respirator&
4 RR( 31(21 breaths per min (count resp for 1 full min because
breathin/ patterns are irre/ular)
4 Apnea- (essations of respirations for more than 2 seconds is
N, normal
$erio#ic 3reathing- (pause in breathing) - describes intermittent
cessation of respirations for less than !" seconds. +his is a
N,R4A5 6"ND"N*B
7"f less than 31breaths8min or greater than 21 breaths8min(
report to charge nurse9
@$bs the mucous membranes for c&anosis (suction w# bulb
syringe $R%& remember suction mouth before nose')
4 "ncrease# RR are seen #uring+
4 Cesp distress
4 (ardiac abnormalities
4 Decrease# RR are seen #uring+
4 &pnea (cessation of respirations for more than D0 sec
4 Resp #istress S8S+ (these are the abnormal signs that
in#icate resp #istress:)
E 8asal farin/
E (ostal or substernal retractions(suckin/ in of the chest
,all ,3 the sternum movin/ in,ard ,3 inspiration)
E Fruntin/ on expiration
emp
4 emp 9;9;(9<92 axillary
4 Decrease# temp seen in#
4 Gith cold stress
4 <etabolic disturbances
4 %nfections
4 "ncrease# temp seen#
. deh.dration
.overdressin/
.infection
3loo# $ressure
16 +aken ,hen newborn is quiet
17 8orn#
60-*0
3
00-=0
mm:/
o Ghen cr&ing or suc.ing (#$ increases from !)2 mm:/
S.in#
If Meconium ,as passed before birth#
18 *reenish brown discoloration of the skin, nails ; cord (.nown as+
meconium stain)
$ost term newborns#
19 'eelin/ or excessive skin crackin/ (des*uamation)
:i/h hemo/lobin level and vasomotor instabilit. 7
20 Acroc&anosis of hands and feet for "
st
,eek (normal)
Cutis marmorata# lacelike red or blue pattern on the skin surface
21 8ormal vasomotor response to lo, environmental temperature
'inkish colored skin. bluish colored hands3feet (acroc&anosis)
Newborn $h&sical Assessment+
= 4ol#ing
4 $verlappin/ of skull bones due to head compression (cone
shape)
-$ccurs as a result of head compression durin/ the birth process.
-Resol%es# ,ithin 2- days
= Caput succe#aneum >
E +ocalized swelling of soft tissues of the scalp
E (aused b. pressure of the head durin/ labor
E <a. cross suture (fontanels) lines
E ,bsorbed within a few days, requires no intervention
= Cephalhematoma >
= (ollection of blood bet,een periosteum3 bone of skull
= <a. be unilateral or bilateral
= H$I9 8$+ cross suture lines
= Hisappearance ma. take as lon/ as 3 ,eeks
Anterior8posterior fontanelle?s+
= Anterior fontanelle+
74ost important for clinical e%aluation
4 !iamond shaped
4 19) to '9) inches in siJe (3.6-6 cm)
4 Closes from 1'(1< months of a/e
4 <a. bul/e ,ith cr. or cou/h but if bul/es ,ith rest si/n of
problem
-Fro,th of head is stimulated b. brain /ro,th, ,hich is mostl.
complete b. D .rs of a/e.
= $osterior fontanelle+
4 "riangle shaped
4 9maller than anterior fontanelle
4 Closes b. '(3 months of a/e(late closure may indicate
hydrocephaly)
-5ate closure of the posterior fontanelle ma. indicate
-Hydrocephaly.
6ontanelle "n#ications#
4 Depresse# fontalenelle 6 often late si/n of #eh&#ration
4 3ulging fontanel- ,hen ne,born is quiet (this should not be
elevated) %f it is it ma. indicate "C$
(& large fontannelle (or #ela&e# closure) ma. indicate-
congenital hypothyroidism.
(& small anterior fontanelle (or earl& closure) ma. indicate-
craniosynostosis (which is associated w# abnormal brain
development.)
6ace
4 (heeks KfullnessK due to the accumulation of fat-,hich makes up
K#uc$ing %adsKand allo,s ne,borns to have a stron/ suc$ing
re&ex.
4 2acial movements should be s.mmetrical.
-+he ne,borns face is sensitive to touch (Rooting re@eA- KcheekK)
B&es
4 %ris slate blue or gra& (lighter complexion babies) 3rown-
usuall. seen ,3 darker complexion babies.
4 (olor established perm- at 3(2 months
4 9ee about !-"0 inches (ne,borns are KmyopicK.)
4 /isual trac.ing#
4 +he &bilit. to follo, obLects (can focus on obLects for about
'( seconds)
4 Can #iscriminate between simple an# compleA
patterns
E +he. prefer simple ones
4 Incoura/e e.e contact (en face), encoura/es parent3ne,born
bon#ing
(Strongest stimuli for a ne,born is the human face9
4 (heck ne,borns pupils for $BRR5A (also check for the blinkin/
refex, ; infammation of the e.elids)
-+he red refex in the retina-absence ma. indicate congenital
cataracts.
-ears durin/ cr.in/ are not normal until ' months of age- tearin/
in the ne,born may indicate con)unctivitis* or glaucoma.
Nose
4 2lat (result of tight s*ueeze during labor and birth)
4 Nose breathers, keep path,a. clear-(obs of mucous can cause
di-culty breathing)
-Nasal $atenc&- is ensured if the ne,born breaths eas. ,3 a
closed mouth. %t can be determined b. holdin/ one naris shut at
a time.
-& piece of cotton ball can be held up to the open nostril to detect
air movement.
4 9neeJin/ is common ( clears nasal passages.)
4 (an smell odors like breast milk, the. can detect it
4outh
4 Chec. for#
4 'alate closure
4 'resence of teeth(usuall. removed-risk of aspiration)
4 Ixcessive saliva
4 %nfection
4 (left palate
4 5arge tongue, (or protruding)- si/n of trisomy 2' or
downs syndrome
4 hrush 6 si/n of infection
4 9uckin/, rootin/, extrusion refexes
@Bpstein?s $earls- small ,hite c.sts resultin/ from
accumulation of epithelial cellMs commonl. found on the
midline of the hard palate. Hisappear a fe, ,eeks after birth.
Bars
4 Assesse# for - 'lacement, formation, ; amount of cartila/e
present (cartila/e should be -rm in +erm 8e,born.)
4 :earin/ test (risk factors for poor hearing are Rubella, congenital
defects of the ear)
4 !earing is establishe# after 1
st
sneeCe(
(which helps clear out .ustachian tube so baby can hear
better.)
-8e,born should respond to rin/in/ bell or human
voice b. becomin/ alert and movin/ the bod.. (donMt for/et
KStartle Re@eAK)
4 Celation of position of the ear to the outer canthus of the e.e#
4 5ow set ears ma. indicate chromosomal disorders or
kidney disease
Nec.
4 8e,born has a -#hort nec$, that is creased ,3 skin folds
4 (annot support the ,ei/ht of head (poor muscle tone). +he head
ma. /lag/ ,hen the bab. is pulled from a supine to a sittin/
position.
@'arents should be tau/ht to support the head b. placin/ a hand
behind the neck so that the head ,ill drop back onl. sli/htl..
-+lavicles should be symmetrical and smooth to the touch0
4 As&mmetrical cla%icles- diNcult deliver. can cause
shoulder d.splasia. $r fractured clavicle from birth trauma.
4 R,4-determined b. observin/ ne,born movin/ head
as far as the shoulder in both directions.
Chest
4 Cound, s.mmetrical, sli/htl. smaller than the head.
-'rotrusion of the xiphoid cartila/e (lower part of the sternum) is
common.
4 Chest measurements ,measured at nipple line-1 3195(
33 cm 2'2-'inch) 3hich is approx 20"cm 2! in4 less than
the head0
4 $osition an# #istance between nipples# (important
measurement)
- &t term-breast tissue mass of =mm or more.
E Histance bet,een- *cm (3 in)
-Gide distance ma. indicate- con/enital defect
4 Oreast en/or/ement common (in both males 5 female) Hue to
hormones from mom.
4 P3itch6s milkQ-ne,born ma. secrete this in the -rst ,eeks.
4 3reath soun#s shoul# be clear
4No retractions (suckin/ in) of intercostal muscles or
substernal chest durin/ inspirations
- Rales or crac.les -indication of fuid in the chest.
Ab#omen
4 &ppears- 9li/htl. protuberant, and s.mmetrical
4 <oves ,ith chest durin/ respiration
-:ealth. ne,born there ma. be visible bul/in/ at the midline of the
abdomen.
- Fap bet,een the rectus muscles is called- KDiastasis RectiK
-7f the abdomen looks distended- abdominal circumference
measurement should be taken.
4 9houldnRt be able to palpate an. masses in there
4 Dmbilical cor## (midway between the xiphoid process 5
symphysis pubis)
@ %nspected immediately after birth for# 7' arteriesE 1
%ein
(A single arter& is associated ,3 congenital
abnormalities.
4 (ord be/ins to dry within a few hrs, shrivels and darkens by
the 2nd or 8rd day and 6alls oF ;(9 #a&s9
3la##er
4 should be inoSensive of odor (foul odor is indicative of infection)
4 1
st
%oi# ma. be dark amber because of uric acid cr.stals and
ma. stain the diaper pink. 6irst /oi#ing , should be
#ocumente# (indicates the urinary system is functioning04
4 9hould have 6 ,et diapers per da..
-&ssessment of s.in turgor, ; cap reGll times, alon/ ,3 the T of
wet #iapers per da.-are assessment parameters for
determining hydration status.
*enitalia
4 <a. be va/inal dischar/e
4 5no,n as# $seu#omenstruation (because of moms
hormones0)
4 !&pospa#ias
4 $penin/ of urinar. meatus in the underside of the penis.
4 Bpispa#ias
4 Urinar. meatus on upper side of penis
4 $himosis
4 2oreskin adheres to the /lands penis (bab. canRt void the. do
emer/enc. circumcision)
4 +estes should be descended b. birth
4 Cr&ptorchi#ism# undescended testes
Anus
4 <ust be open
4 /llows passage of meconium use petroleum or &;H ointment
so ,hen bab. passes it itRs easier to take meconium oS.
7Documentation of Grst meconium passage is important an#
must be passe# before D8C9
4 ,bstruction if ne,born has not had stool for ') hours9
4 3reast fe##
4 9hould have more than 3 stools a da., ,ater. but shoul#
not be ,ater. enou/h to overfo, the diaper.
4 3ottle fe##
4 Aess frequent stools
4 Om can be ever. other da. (this is considered normal.)
@Ghether bottle fed or breast fed a soft stool indicates that
constipation is 8$+ present.
@1 ounce of KSorbitolK- containin/ pear, prune, or apple Luice
ma& be gi%en for constipation.
3ac.
4 9trai/ht, fat (lumbar and sacral curves do not develop until
baby begins to sit)
4 &ssess spine for dimples, masses and hair tufts(a few hairs) and
spinal curvatures.
4 ,rtolani maneu%ers#
4 %s done to examine for hip #islocation8congenital
#&splasia. (AB3- as.mmetric skin folds, limited aOduction)
4 &ssess for /luteal ;popiteal folds (creases of the thi/hs)
should be s.mmetric on both sides.
BAtremities
4 $ol&#act&l&# (inherited dominant trait)
4 Ixtra di/its
4 S&n#act&l&# (ma. occur as a hereditar. trait)
4 Gebbin/ of di/its
4 Simian crease (one line across the palm)#
4 Ho,ns s.ndrome
4 (lub foot
- KBrb?s $als&K (.rb)9unchenne $aralysis)- noted if ne,borns arm
lies limpl. at the side or if ne,born is unable to elevate arm.
$rthopedic medical care must be immediatel. started for this
condition.
-Unilateral K4oro?s Re@eAK- ma. indicate a fractured clavicle
(diNcult deliver..)
-6emoral pulses shoul# be palpate#- diminished or unequal
femoral pulses ma. indicate a heart defect- speci-call.
Coarctation of he Aorta.
Neuro+
-Hone to determine if the ne,borns nervous s.stem is intact.
- %mportant to obtain baseline info on- /eneral behaviors,
restin/ posture, cr., qualit. of muscle activit., and state of alertness.
@Newborn remors-are common. +he. must be assessed to rule out
convulsions.
-SeiCures ma& consist of# excessive blinkin/, che,in/, or
s,allo,in/ movements.
3eha%ioral States#
4 Acti%e alertness 6 8O demonstrates stron/ suck. Food time to breast
feed. '/ "*0("0th ed)
4 30 min to " hour becomes dro,s. and falls asleep. Aasts 2-0
hours.
4 '
n#
perio# of reacti%it&-a,ake, alert, and ma. cr.. Cootin/,
suckin/, s,allo,in/ seen.
4 Aasts 0-6 hours
4 Huiet alert state# best time to obser%e responses
-I.es open
Screening+
- 9creenin/ testMs are used to detect the presence of an
abnormal condition before s3s appear.
- N, a D"A*N,S"C ,,5. (positive screenin/ test
indicates a need for f3u.)
-+he main purpose of a screenin/ test is to enable earl&
inter%ention.
- ,ptimum time to perform a screening test is-
3efore the 5th #a& of life in a health& newborn.
4an#ate# Screening (in A55 states)
-:.perth.roidism
-$ID- (condition in ,hich the ne,born cannot
metaboliJe phen.lalanine >,hich is present in milk? and it accumulates
in the blood, causin/ mental retardation.
ReleAes- 9uckin/, ton/ue extrusion, moro, /rasp(palmer), babinski,
rootin/, tonic neck, suckin/, steppin/. (chart in book, % ma. make a mini
one for ever.one thou/h if % have time.)