Newborn assessmentGeneral appearanceWell-flexed, full range of motion, spontaneous movement Common variationsLegs extended with frank breech

Signs of potential distress or deviations from expected findingsPosture limp Asymmetry of movement Persistent tremor, twitching

Vital SignsTemperature - range 36.5 to 37 axillary Common variationsCrying may elevate temperature Stabilizes in 8 to 10 hours after delivery

Signs of potential distress or deviations from expected findingsTemperature is not reliable indicator of infection A temperature less than 36.5

Heart rate - range 120 to 160 beats per minute Common variationsHeart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying

Signs of potential distress or deviations from expected findingsAlthough murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound

Respiration - range 30 to 60 breaths per minute

Common variationsBilateral bronchial breath sounds Moist breath sounds may be present shortly after birth

Signs of potential distress or deviations from expected findingsAsymmetrical chest movements Apnea >15 seconds Diminished breath sounds Seesaw respirations Grunting Nasal flaring Retractions Deep sighing Tachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor

Blood pressure - not done routinely Factors to considerVaries with change in activity level Appropriate cuff size important for accurate reading Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities

Sign of potential distress or deviations from expected findingsCalf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta

General MeasurementsHead circumference - 33 to 35 cm Expected findingsHead should be 2 to 3 cms larger than the chest

Chest circumference - 30.5 to 33 cm Common variationsMolding of head may result in a lower head circumference measurement Head and chest circumference may be equal for the first 24 to 48 hours of life

Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)

Length range - 48 to 53 cms (19 - 21 inches)

SkinExpected findingsSkin reddish in color, smooth and puffy at birth

At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals Vernix caseosa Lanugo Turgor good with quick recoil Hair silky and soft with individual strands Nipples present and in expected locations Cord with one vein and two arteries Cord clamp tight and cord drying Nails to end of fingers and often extend slightly beyond

Common variationsAcrocyanosis - result of sluggish peripheral circulation

Mongolian spots in infants of African-American descent

Mottling

Physiologic jaundice

Milia

Erythema toxicum

Petechiae/ bruises over presenting part Skin tags usually around ears or digits (tied off) Harlequin color change

Signs of potential distress or deviations from normal findingsJaundice within 24 hours of birth General cyanosis Circumoral cyanosis between feedings Petechiae or ecchymoses other than on presenting part All rashes with exception of erythema toxicum Pigmented nevi Yellow vernix Hemangioma Pallor Forceps marks

HeadExpected findingsAnterior fontanel diamond shaped 2-3 - 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat Sutures palpable with small separation between each

Common variationsCaput succedaneum

Molding of fontanels and suture spaces

Signs of potential distress or deviations from normal findings

Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalhematoma

Closed sutures

EyesExpected findingsSlate gray or blue eye color No tears Fixation at times - with ability to follow objects to midline Red reflex Blink reflex Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light

Common variationsEdematous eyelids

Uncoordinated movements

May focus for a few seconds

Signs of potential distress or deviations from expected findingsDischarges Chemical conjunctivitis

Opaque lenses Absence of Red Reflex Epicanthal folds in newborns not of Oriental descent "Doll's eyes" beyond 10 days of age Reflexes absent Subconjunctival hemorrhage

EarsExpected findingsPinna top on horizontal line with outer canthus of eye

Loud noise elicits Startle Reflex Flexible pinna with cartilage present

Common variationsSkin tags on or around ears

Signs of potential distress or deviations from expected findingsEar placement low Preauricular sinus

Clefts present Malformations Cartilage absent

NoseExpected findings

Nostrils patent bilaterally Obligate nose breathers No nasal discharge

Common variationsSneezes to clear nostrils Bridge appears absent Thin white nasal mucus discharge

Signs of potential distress or deviations from expected findingsChoanal atresia and discharge Malformation Nasal flaring beyond first few moments after birth

Mouth and ThroatExpected findingsMucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.

Palate high arched

Uvula midline Minimal or absent salivation Tongue moves freely and does not protrude Well developed fat pads bilateral cheeks Sucking reflex Rooting reflex Gag reflex Extrusion reflex

Common variationsEpstein's pearls on ridges of gums

Signs of potential distress or deviations from expected findingsCleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete

Protruding tongue Candida Albicans

Diminished tongue movement Precocious teeth

NeckExpected findingsShort and thick Turns easily side to side Clavicles intact Tonic neck reflex present Neck-righting reflex present Some head control

Signs of potential distress or deviations from expected findingsTorticollis-stiff neck drawing head to one side Resistance to flexion Webbing of neck

Large fat pad on back of neck Palpable crepitus, movement with palpation of clavicle

ChestExpected findingsEvident xiphoid process Equal anteroposterior and lateral diameter Bilateral synchronous chest movement Symmetrical nipples

Common variations"Witch's milk" Enlarged breasts Accessory nipples

Signs of potential distress or deviations from expected findingsAsymmetrical chest movements Sternum depressed Marked retractions Absent breast tissue Flattened chest Supernumerary nipples Nipples widely spaced Bowel sounds auscultated

AbdomenExpected findingsDome-shaped abdomen Abdominal respirations Soft to palpation

Well formed umbilical cord Three vessels in cord Cord dry at base Liver papable 2 - 3 cms below right costal margin Bilaterally equal femoral pulses Bowel sounds auscultated within two hours of birth Voiding within 24 hours of birth Meconium within 24 - 48 hours of birth

Common variationsSmall umbilical hernia

Signs of potential distress or deviations from expected findingsBowel sounds absent Peristaltic waves visible Abdominal distention Palpable masses Scaphoid-shaped abdomen Omphalocele Base of cord with redness or drainage Cord with two vessels

Female GenitaliaExpected findingsEdematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia

Common variationsHymenal tag Pseudomenstruation Smegma Increased pigmentation Ecchymosis and edema after breech birth "Red brick" pink-stained urine due to uric acid crystals Signs of potential distress or deviations from expected findings Labia fused Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia

Male GenitaliaExpected findings Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voiding Common variations

Prepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech deliverySigns of potential distress or deviations from expected findings Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia

Back and RectumExpected findingsIntact spine without masses or openings Trunk incurvature reflex Patent anal opening "Wink reflex" present

Signs of potential distress or deviations from expected findingsLimitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cyst

Extremities

Expected findingsMaintains posture of flexion Equal and bilateral movement and tone Full range of motion all joints Ten fingers and ten toes Legs appear bowed Feet appear flat

Palmar creases present

Sole creases present

Negative hip click Grasp reflex present

Signs of potential distress or deviations from expected findingsUnequal tone Asymmetrical movement of extremities Polydactyly

Syndactyly Unequal leg length Asymmetrical skin creases posterior thigh

Dislocation of hip

Simean crease Persistent cyanosis of nail beds Marked metatarus varus

Neuromuscular SystemExpected findingsMaintains postion of flexion When prone, turns head side to side Holds head and back in horizontal plane when held prone Ability to hold head momentarily erect

Signs of potential distress or deviations from expected findingsHypotonia Quivering Limp extremities or straightening of extremities Clonic jerking Paralysis