physical assessment of newborn

8/6/2019 Physical Assessment of Newborn

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Normal Newborn: GeneralAppearance

Well-flexed, full range of motion, spontaneousmovement

Common variations:

Legs extended with frank breech

Signs of potential distress or deviations fromexpected findings:

Posture limpAsymmetry of movement

Persistent tremor, twitching


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Vital Signs and General Measurements Temperature - Range 36.5 to 37 axillary

Common variations: Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery

Signs of potential distress or deviations from expected findings: Temperature is not reliable indicator of infection A 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 crying Color pink with acrocyanosis Heart rate may be irregular with crying

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

Faint sound`


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Respiration - Range 30 to 60 breaths per minute

Common variations:

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

Signs of potential distress or deviations from expectedfindings: Asymmetrical chest movements

Apnea >15 seconds Diminished breath sounds Seesaw respirations Grunting Nasal flaring Retractions Deep sighingTachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor (Crowing respiratory sound)


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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 fromexpected findings:Calf systolic pressure 6 to 9 mm Hg less than systolic

pressure in upper extremities may be indicative ofcoarctation of the aorta


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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

measurementHead and chest circumference may be equal for the first 24 to 48

hours of life

*Molding refers to the process by which the neonates head is shaped during labor as itpasses through the birth canal. The head may become elongated due to theoverlapping of the cranial bones at the suture lines.

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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SkinExpected Findings:

Skin reddish in color, smooth and puffy at birthAt 24 - 36 hours of age, skin flaky, dry and pink incolor

Edema around eyes, feet, and genitals

Turgor good with quick recoil

Cord with one vein and two arteries

Cord clamp tight and cord drying

Hair silky and soft with individual strands

Nipples present and in expected locations

Nails to end of fingers and often extend slightlybeyond

Vernix caseosa - The white, cheesy substancecovering the newborn's body. Often present only in theskin folds.

Lanugo - Fine downy body hair usually distributed overshoulders, sacral area, and back of newborns. Usuallydisappears before birth or shortly after birth.


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Common variations:

ACROCYANOSISThe result of sluggishperipheral circulation.


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MONGOLIAN SPOTS

Patch of purple-black or blue-black colordistributed over coccygeal and sacralregions of infants of African-American orAsian descent.

Not malignant.

Resolves in time.


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MOTTLING

Generalized red and white discolorationof skin of chilled infants with faircomplexion.


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PHYSIOLOGIC JAUNDICEHyperbilirubinemia not associated with hemolyticdisease or other pathology in the newborn.

Jaundice that appears in full term newborns 24 hoursafter birth and peaks at 72 hours. Bilirubin may reach 6

to 10 mg/dl and resolve in 5 to 7 days.


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MILIA

Tiny white papules (pluggedsebaceous glands) locatedover nose, cheek, and chin.


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ERYTHEMATOXICUM

Petechiae/bruises over presenting part.

Petechiae: Pinpoint, flat hemorrhages often visualizedon head, face, and chest. Associated with rapid onset ofpressure followed by immediate release of pressureduring birthing process.

Bruises/Ecchymoses: Larger than petechia, hemorrhagic

areas associated with rapid delivery or breech birth.

Skin tags usually around ears or digits (tied off)

Harlequin coloring - The color of the newborn's bodyappears to be half red and half pale. This condition istransitory and usually occurs with lusty crying. HarlequinColoring may be associated with to an immature

vasomotor reflex system.


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Jaundice (within 24 hours of birth) - Unconjugated bilirubin circulating in theblood stream that is deposited in the skin. Skin color may range from yellow toorange to greenish hues.

General cyanosis

Circumoral cyanosis between feedings

Petechiae or ecchymoses other than on presenting part

All rashes with exception of erythema toxicumPigmented nevi

Yellow vernix

Hemangioma

Pallor

Forceps marks


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Molding of fontanels and suture spaces


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Cephalhematoma

Subperiosteal extravasation of blood duerupture of vessels. Swelling increases in sizeon second and third day after delivery. Oftenassociated with delivery by forceps. Swellingdoes not cross suture line and may takeseveral weeks after birth. Jaundice may occur

as blood cells are broken down as the swellingresolves.

Hydrocephalus

Macrocephaly

Closed sutures


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Eyes

Expected findings:

Slate gray or blue eye colorNo tearsFixation at times - with ability to follow objects to

midlineRed reflexBlink reflex

Distinct eyebrowsCornea bright and shinyPupils equal and reactive to light


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CommonVariations:

Edematous Eyelids May focus for a few seconds

Uncoordinated movements


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Signs of potential distress or deviations from

expected findings:DischargesOpaque lenses

Absence of Red Reflex

Epicanthal folds in newborns not of Oriental descent

Reflexes absent

"Doll's Eyes" Reflex (beyond 10 days of age):When the head is moved slowly to the right or left, the eyesdo not follow nor adjust immediately to the position of the

head. This reflex should not be elicited once fixation ispresent. The persistence of the Doll's Eyes Reflex suggestsneurologic damage.


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Chemical

conjunctivitis

Subconjunctivalhemorrhage


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Ears

Expected findings:

Loud noise elicits StartleReflex

Flexible pinna withcartilage present Pinna top on horizontal linewith outer canthus of eye


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Ear placement low

Clefts present

Malformations Cartilage absent

Preauricular sinus


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Nose

Expected findings:

Nostrils patent bilaterally

Obligate nose breathers

No nasal discharge

Common variations:

Sneezes to clear nostrils

Bridge appears absent

Thin white nasal mucus

discharge


Choanal atresia and discharge Malformation Nasal flaring beyond first few moments after birth


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Mucosa moist

Shortly after birth mayvisualize sucking calluses oncentral portions of lips.

PalateHigh arched


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Commonvariations:

Epstein's pearls on ridgesof gums

Signs of potential distress or deviations fromexpected findings: Cleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete Protruding tongue Diminished tongue movement


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CandidaAlbicans

Percocious teeth


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Neck

Expected findings:Short and thickTurns easily side to sideClavicles intactTonic neck reflex present

Neck-righting reflex presentSome head control

Signs of potential distress or deviations from expectedfindings:

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 process

Equal anteroposterior andlateral diameter

Bilateral synchronous chestmovement

Symmetrical nipples

Common variations:

"Witch's milk"

Enlarged breasts

Accessory nipples


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Asymmetrical chest movements

Sternum depressed

Marked retractions

Absent breast tissueFlattened chest

Supernumerary nipples

Nipples widely spaced

Bowel sounds auscultated


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Abdomen

Expected findings:Dome-shaped abdomenAbdominal respirationsSoft to palpationWell formed umbilical cord

Three vessels in cordCord 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


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Bowel sounds absent

Peristaltic waves visible

Abdominal distention

Palpable masses

Scaphoid-shaped abdomenOmphalocele

Base of cord with redness or drainage

Cord with two vessels


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Genitalia

Female Male

Expected findings: Edematous labia and clitoris

Labia majora are larger and surrounding labiaminora

Vernix between labia

Common variations:

Hymenal tag

Pseudomenstruation Smegma

Increased pigmentation

Ecchymosis and edema after breech birth

"Red brick" pink-stained urine due to uric acidcrystals


Labia fused Fecal discharge from vaginal opening

Imperforate hymen

Ambiguous genitalia

Widely separated labia

Expected 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

delivery

Signs of potential distress or deviationsfrom expected findings:

Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia


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es

Expected findings:

Maintains posture of

flexionEqual and bilateralmovement and tone

Full range of motion alljoints

Ten fingers and ten toes

Negative hip clickGrasp reflex present

Legs appear bowed

Feet appear flat

Palmar creases present Sole creases present

Signs of potential distress or deviations from


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g pexpected findings:

Unequal tone

Asymmetrical movement ofextremities

Syndactyly

Unequal leg length

Dislocation of hip

Persistent cyanosis of nail beds

Asymmetrical skin creasesposterior thigh

Polydactyly

Simean crease

Marked metatarus varus


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Neuromuscular System

Expected findings:Maintains 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 findings:

Hypotonia

Quivering

Limp extremities or straightening of extremities

Clonic jerkingParalysis


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REFERENCESBurns, 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 newbornnursing,Philadelphia; W. B. Saunders Company.

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

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

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