Normal Newborn: General Appearance

 

Well-flexed, full range of motion, spontaneous movement

Common variations

Legs extended with frank breech

Signs of potential distress or deviations from expected findings

Posture limpAsymmetry of movementPersistent tremor, twitching

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Vital Signs

Temperature - range 36.5 to 37 axillary

Common variations

Crying may elevate temperatureStabilizes in 8 to 10 hours after delivery

Signs of potential distress or deviations from expected findings

Temperature is not reliable indicator of infectionA temperature less than 36.5

Heart rate - range 120 to 160 beats per minute

Common variations

Heart rate range to 100 when sleeping to 180 when cryingColor pink with acrocyanosisHeart rate may be irregular with crying

Signs of potential distress or deviations from expected findings

Although murmurs may be due to transitional circulation-all murmursshould be followed-up and referred for medical evaluation

Deviation from rangeFaint sound

Respiration - range 30 to 60 breaths per minute

Common variations

Bilateral bronchial breath soundsMoist breath sounds may be present shortly after birth

Signs of potential distress or deviations from expected findings

Asymmetrical chest movementsApnea >15 secondsDiminished breath soundsSeesaw respirationsGruntingNasal flaringRetractionsDeep sighingTachypnea - respirations > 60Persistent irregular breathingExcessive mucusPersistant fine cracklesStridor

Blood pressure - not done routinely

Factors to consider

Varies with change in activity levelAppropriate cuff size important for accurate readingAverage newborn (1 to 3 days) oscillometry pressure value: 65/41 in

both upper and lower extremities

Sign of potential distress or deviations from expected findings

Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta

General Measurements

Head circumference - 33 to 35 cm

Expected findings

Head should be 2 to 3 cms larger than the chest

Chest circumference - 30.5 to 33 cm

Common variations

Molding 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)

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Skin

Expected findings

Skin reddish in color, smooth and puffy at birth

At 24 - 36 hours of age, skin flaky, dry and pink in colorEdema around eyes, feet, and genitalsVernix caseosa LanugoTurgor good with quick recoilHair silky and soft with individual strandsNipples present and in expected locationsCord with one vein and two arteriesCord clamp tight and cord dryingNails to end of fingers and often extend slightly beyond

Common variations

Acrocyanosis - result of sluggish peripheral circulation

Mongolian spots in infants of African-American descent

Mottling

Physiologic jaundice

Milia

Erythema toxicum

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

Signs of potential distress or deviations from normal findings

Jaundice within 24 hours of birthGeneral cyanosisCircumoral cyanosis between feedingsPetechiae or ecchymoses other than on presenting partAll rashes with exception of erythema toxicumPigmented neviYellow vernixHemangiomaPallorForceps marks

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Head

Expected findings

Anterior fontanel diamond shaped 2-3 - 3-4 cmsPosterior fontanel triangular 0.5 - 1 cmFontanels soft, firm and flatSutures palpable with small separation between each

Common variations

Caput succedaneum

Molding of fontanels and suture spaces

Signs of potential distress or deviations from normal findings

Fontanels that are bulging or depressedHydrocephalusMacrocephalyCephalhematoma

Closed sutures

Eyes

Expected findings

Slate gray or blue eye colorNo tearsFixation at times - with ability to follow objects to midlineRed reflexBlink reflexDistinct eyebrowsCornea bright and shinyPupils equal and reactive to light

Common variations

Edematous eyelids

Uncoordinated movements

May focus for a few seconds

Signs of potential distress or deviations from expected findings

DischargesChemical conjunctivitis

Opaque lensesAbsence of Red ReflexEpicanthal folds in newborns not of Oriental descent"Doll's eyes" beyond 10 days of age

Reflexes absentSubconjunctival hemorrhage

Ears

Expected findings

Pinna top on horizontal line with outer canthus of eye

Loud noise elicits Startle ReflexFlexible pinna with cartilage present

Common variations

Skin tags on or around ears

Signs of potential distress or deviations from expected findings

Ear placement lowPreauricular sinus

Clefts presentMalformationsCartilage absent

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Nose

Expected findings

Nostrils patent bilaterallyObligate nose breathersNo nasal discharge

Common variations

Sneezes to clear nostrilsBridge appears absentThin white nasal mucus discharge

Signs of potential distress or deviations from expected findings

Choanal atresia and dischargeMalformationNasal flaring beyond first few moments after birth

Mouth and Throat

Expected findings

Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.

Palate high arched

Uvula midlineMinimal or absent salivationTongue moves freely and does not protrudeWell developed fat pads bilateral cheeksSucking reflexRooting reflexGag reflexExtrusion reflex

Common variations

Epstein's pearls on ridges of gums

Signs of potential distress or deviations from expected findings

Cleft lip or cleft palateCircumoral pallorLip movement asymmetricalReflexes absent or incompleteProtruding tongueCandida Albicans

Diminished tongue movementPercocious teeth

Neck

Expected findings

Short and thickTurns easily side to sideClavicles intactTonic neck reflex presentNeck-righting reflex presentSome head control

Signs of potential distress or deviations from expected findings

Torticollis-stiff neck drawing head to one sideResistance to flexionWebbing of neckLarge fat pad on back of neckPalpable crepitus, movement with palpation of clavicle

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Chest

Expected findings

Evident xiphoid processEqual anteroposterior and lateral diameter Bilateral synchronous chest movementSymmetrical nipples

Common variations

"Witch's milk"Enlarged breastsAccessory nipples

Signs of potential distress or deviations from expected findings

Asymmetrical chest movementsSternum depressedMarked retractionsAbsent breast tissueFlattened chestSupernumerary nipplesNipples widely spaced Bowel sounds auscultated

Abdomen

Expected findings

Dome-shaped abdomenAbdominal respirationsSoft to palpationWell formed umbilical cordThree vessels in cord

Cord dry at baseLiver papable 2 - 3 cms below right costal marginBilaterally equal femoral pulsesBowel sounds auscultated within two hours of birthVoiding within 24 hours of birthMeconium within 24 - 48 hours of birth

Common variations

Small umbilical hernia

Signs of potential distress or deviations from expected findings

Bowel sounds absentPeristaltic waves visibleAbdominal distentionPalpable massesScaphoid-shaped abdomenOmphaloceleBase of cord with redness or drainageCord with two vessels

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Back and Rectum

Expected findings

Intact spine without masses or openingsTrunk incurvature reflexPatent anal opening"Wink reflex" present

Signs of potential distress or deviations from expected findings

Limitation of movementFusion of vertebraeSpina bifidaTuft of hairImperforate anusAnal fissuresPilonidal cyst

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Back and Rectum

Expected findings

Intact spine without masses or openingsTrunk incurvature reflexPatent anal opening"Wink reflex" present

Signs of potential distress or deviations from expected findings

Limitation of movementFusion of vertebraeSpina bifidaTuft of hairImperforate anusAnal fissuresPilonidal cyst

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Extremities

Expected findings

Maintains posture of flexionEqual and bilateral movement and toneFull range of motion all joints Ten fingers and ten toesLegs appear bowedFeet appear flat

Palmar creases present

Sole creases present

Negative hip clickGrasp reflex present

Signs of potential distress or deviations from expected findings

Unequal toneAsymmetrical movement of extremitiesPolydactyly

SyndactylyUnequal leg lengthAsymmetrical skin creases posterior thigh

Dislocation of hip

Simean creasePersistent cyanosis of nail bedsMarked metatarus varus

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Neuromuscular System

Expected findings

Maintains postion of flexionWhen prone, turns head side to sideHolds head and back in horizontal plane when held proneAbility to hold head momentarily erect

Signs of potential distress or deviations from expected findings

HypotoniaQuiveringLimp extremities or straightening of extremitiesClonic jerkingParalysis

To return to Table of Contents. This product is still being developed. Acknowledgement:Special thanks to Robert, Barbara, and Allison Clifford for their participation in the preparation of the video clips used in this presentation.

References:Burns, C.E., Barber, N., Brady, M.A., Dunn, A.M., (1996) Pediatric Primary Care: A Handbook for Nurse Practitioners, Philadelphia, W.B. Saunders Company.

Gorrie, Trula Myers, McKinney, Emily Stone, and Murray, Sharon Smith. (1994). Foundations of maternal newborn nursing,Philadelphia; W. B. Saunders Company.

Wong, Donna L. (l995). Whaley & Wong's nursing care of infants and children; contributing editor, David Wilson. 5th edition. St. Louis: Mosby.

Variations and minor departures in infants (1994), Mead Johnson & Company: Evansville, Indiana.

Resources:CCIT staff, Duquesne University.Created by Lenore K. Resick, MSN, RN, CS, CRNP, 612 College Hall 412/396-5228, e-mail: resick@duq.eduCopyright 1996 Duquesne University