LEXINGTON COMMUNITY COLLEGE Associate Degree Nursing Nursing 235 Spring 1999 NEWBORN ASSESSMENT GUIDE Assessment I.

GENERAL MEASUREMENTS a. Age b. Weight c. Length d. Apgar Score II. HEAD MEASUREMENT a. Shape Round symmetrical may have molding--> overriding sutures. Slight asymmetry. 33-35 cm 2 cm> chest circ Term = start of 38th wk. end of 42nd week. 6.5-7.75 lbs 18-20.5 in 45-52.3 cm 7-10 <7 Textbook Information

Client’s Initials ________ Date of Birth ________ Gestational Age ________

Possible Major Deviations and Complications

Infant Observation

preterm = before end of 37th wk. posterm = after end of 42nd wk. <6 lbs >9 lbs

Microcephaly <32 cm Hydrocephaly >4 cm from chest Cephalohematoma

b. Size in relation to body

Assessment c. Fontanels size, shape, consistency 1. Anterior

Textbook Information Sutures, palpable slight pulsation Soft 3-4 cm long 2-3 cm wide diamond shape 1-2 cm triangular

Possible Major Deviations and Complications Full bulging, large, depressed Closed sutures

Infant Observation

2. Posterior III. EYES a. Color b. Movement

Grayish blue or gray brown iris. Blue white sclera. Random, jerky, uneven. Focus momentarily. Follows to midline. Pupils equal in size, round and reactive to light. May turn toward soft light. Without or occasionally. Focuses and follows by 15 min of age. See above, reaction to light.

Jaundiced sclera. Gross nystagmus Constant Strabimus Doll’s eye’s > 10 d. Pupils unequal, restricted, dilated, fixed Discharge Does not respond to light, focus or follow.

c. Reaction to Light

d. Tears e. Evidence of sight

Assessment f. Eyelids

Textbook Information Size and movement symmetric. Blink reflex. Edema from prophylaxis. Eyes on a parallel plane.

Possible Major Deviations and Complications Does not respond to light, focus, or follow.

Infant Observation

IV. EARS a. reaction to noise Startle reflex to loud noise. Attends to sound. By 15 min. of age may move eyes in direction of sound. Responds to crooning by relaxation. Line drawn through inner and outer canthi of eye comes to top notch of ear (where it connects with scalp.) Symmetrical. Evidence of hearing. Reaction to noise. Midline Clear Infants obligatory nose breathers. Sneezing is common. Copius drainage Cyanosis at rest. Flaring or nares. Absence of reaction.

b. Position

Low placement

c. Patency V. NOSE a. Mucus b. Patency

Assessment c. Reflexes 1. Sucking 2. Swallow 3. Gag VI. MOUTH

Textbook Information Dependent on state of wakefullness and hunger.

Possible Major Deviations and Complications

Infant Observation

See Section XXI. REFLEXES Symmetrical Presence of gag and swallowing Hard & soft palate in tact Epstein’s Pearls Mouth drawls to one side

Clefts VII. NECK a. Length b. Mobility Short, thick, surrounded by skin folds. Head held midline. Free movement from side to side. Full flexion and extension. Cannot move head past shoulder. Webbing Rigid. Restricted movement. Head held at angle. Without head control. VIII. CHEST a. Size b. Breast tissue 1-2 cm <head circ. 30-33 cm 3-10 mm breast nodule Nipples prominent <30 cm Lack of breast tissue

Assessment c. Characteristic shape

Textbook Information Almost circular. Barrel shaped.

Possible Major Deviations and Complications Bulging of chest. Retractions. Bowel sounds in chest.

Infant Observation

IX.

RESPIRATIONS a. Rate b. Rhythm c. Breath Sounds 30-60/min Shallow. Irregular when infant awake. No sounds heard without stethoscope. Bronchial. Loud, clear, near. d. Muscular activity involved Simultaneous rise and fall of chest and abdomen. Diaphragmatic and abdominal breathing. Tachypnea > 60/min Bradypnea < 25/min Labored breathing. Grunting, rales, rhonchi, wheeze (with or without stethoscope) Apnea > 15 sec. Subcostal and substernal retractions. Flaring of nares. Chin tug.

X.

PULSE a. Rate 120-160/min. 180 with crying 100/min. if asleep May be irregular for brief periods especially after crying. Persistent tachycardia-- > 170 Bradycardia-- < 120 Persistent irregular rhythm.

b. Rhythm

Assessment c. Peripheral circulation XI. ARMS AND HANDS a. Length b. Movements c. Muscle tone

Textbook Information Femoral pulses palpable, equal, strong. Sluggish peripheral circulation.

Possible Major Deviations and Complications Weak or absent.

Infant Observation

Arms equal in length. Arms longer than legs. Spontaneous. Full range of motion. Generally flexed. Fist often clenched with thumb under finger.

Anelia, phocomelia Limited movements. Asymmetry of movements. tonicity Asymmetric contour. Poor tone/floppy. + scarf sign.

d. Fingers 1. Number 2. Webbing e. Position XII. ABDOMEN a. Contour Rounded, protruding Abd. distended. Scaphoid. Correct Without Fists often clenched with thumb under finger. Absence of or additional. Short. Polydactyl Syndactyl Rigid flexion. Persistent fists.

Assessment b. Musculature

Textbook Information Not fully developed. Bowel sounds audible 1-2 hours after birth.

Possible Major Deviations and Complications Sounds in chest.

Infant Observation

XIII.

UMBILICAL CORD a. Number of vessels at birth b. Appearance 2 arteries 1 vein Clear, gelatin. Odorless. Drying. 1 artery Bleeding or oozing. Drainage or redness.

XIV.

GENITAL-URINARY a. Female 1. Labia a. Size b. Appearance 2. Vaginal discharge a. Color b. Type Smegma under labia. May be blood tinged. Mucoid/white Usually edematous Covers labia minora May have pigment. Symmetric in size. Majora widely separated Minora prominent. Absence of vaginal orifice. Fecal discharge. Ambiguous genitals

Assessment b. Male 1. Testes in scrotum 2. Urethral meatus at end of penis 3. Circumcised

Textbook Information

Possible Major Deviations and Complications Ambiguous genitals

Infant Observation

Palpable each side. Large. Rugge. Cremasteric. Correct position. Prepuce covers glans. Not easily retractable. Yes or no. By day 2 white exudate may cover glans penis.

Undescended. Scrotum smooth. Not at tip of penis. Adherent prepuce. Excessive bleeding, swelling or discharge.

c. Voidings 1. Color 2. Amount 3. Frequency 4. Specific gravity XV. RECTUM a. Patency Good sphincter tone of anus. Good wink reflex. Clear, light yellow. Well saturated diapers By 24 hrs after delivery. At least 3-4 times/day 1.008-1.010

Assessment b. Stools 1. Number 2. Color 3. Consistency 4. Frequency XVI. HIPS a. Symmetry b. Femur heads XVII. BACK a. Appearance b. Turns head from side to side in prone position.

Textbook Information

Possible Major Deviations and Complications

Infant Observation

Meconium by 24 hrs. after birth. Depends on age of infant and type of feeding she is receiving. See your book for specifics.

Failure to pass meconium. Abd. distention. Diarrhea—curdy, green, large water ring, forceful.

Gluteal folds even Intact No protrusion.

Congenital hip dysplasia

Straight, easily flexed. Yes Can raise head momentarily. Limitation of movement. Pigmented nevus with tuft of hair located at base of spine. Spina bifida.

XVIII. LEGS AND FEET a. Appearance May appear to have bowed legs.

Assessment 1. Warmth b. Length c. Movement d. Alignment Equal

Textbook Information

Possible Major Deviations and Complications Different temps. Unequal Hypermobility. Lack of leg movement. Club foot.

Infant Observation

Legs of equal length. Shorter than arms. Full ROM Foot in straight line. May appear to turn in but easily rotated externally. General flexion Feet flat. Well lined over 2/3 of surface. Correct Without General flexion. Most often see legs drawn up against abd.

e. Muscle tone f. Toes 1. Number 2. Webbing g. Position XIX. SKIN a. Color

Absent or excessive digits. Syndactyly Rigid or floppy posture.

Generally pink. Acrocyanosis. May see some mottling.

Jaundice. Cyanosis. Pallor or dark red.

Assessment b. Textures

Textbook Information Smooth, soft. Flexible.May have dry peeling hands and feet. Without edema. Teleangiectases Mongolian spots. Transient hyperpigmentation of areolas, genitals.

Possible Major Deviations and Complications Thinner or thicker texture. Fish scale skin. Hemangiomas

Infant Observation

c. Birthmarks

d. Characteristics 1. Milia 2. Lanugo 3. Vernix caseosa 4. Ecchymosis 5. Hair Distended sebaceous glands particularly on nose and cheeks. Over shoulder, pinnias, forehead, back. White, cheesy, odorless. In creases and folds. Peteciae over presenting part. Ecchymosis from forceps. Amount varies. Silky, growth pattern toward face and neck. Absent or excessive. Absent of excessive. Yellow, green or foul odor. Over other areas. Fine, woolly. Coarse, brittle. Unusual growth pattern.

Assessment 6. Nails 7. Peeling XX. TEMPERATURE a. Normal b. Temperature regulatory mechanism c. Heat Loss

Textbook Information Present, extended beyond fingertips. Of hands and feet at about day 3.

Possible Major Deviations and Complications Absence. Generalized cracking and/or peeling.

Infant Observation

97.6-98.6 axillary Shivering mechanism undeveloped. Brown fat. From evaporation, conduction, convection, radiation.

<97 Ax. >99 Ax. Temp not stabilized by 10 hrs after birth. Swings of > 2° F from one reading to the next.

XXI.

REFLEXES a. Local 1. Blink Response to light stimulus. Tap on forehead, bridge of nose, maxilla when eyes open—blink first 4-5 times. Response to light is equal. Round. Pupil constricts. Continued blinking with repeated taps. Failure to respond. Response unequal.

2. Pupillary

Assessment 3. Doll’s eyes 4. Rooting 5. Sucking/swallowing

Textbook Information When head is turned, eye movement lags behind. Turns head in direction of stimulus, opens mouth. Follows rooting. Takes hold, sucks ad obtains fluids. Safety reflex. Do not try to elicit. Spontaneous. Finger curl around examiner’s finger. Toes turn downward. Hyperextension of all toes with dorsiflexion of big toe when one side of sole is stroked from heel across ball of foot to toe.

Possible Major Deviations and Complications

Infant Observation

Weak or absent. Weak or absent. Gagging, coughing or vomiting with swallowing.

6. Gag 7. Yawn 8. Grasp 9. Babinski

Absent.

Assessment b. Generalized 1. Moro (Startle)

Textbook Information

Possible Major Deviations and Complications

Infant Observation

Symmetric abduction and extension of arms. Finger may fan with forefinger and thumb forming a C. Arms then adduct in embracing motion and return to relaxed flexion. When head is turned to one side, extremities on same side extend and on opposite side flex. when held upright with one foot touching a flat surface, will stimulate walking. Will step alternately. While on abdomen, will make crawling movements with arms or legs. Asymmetry of stepping.

2. Tonic neck (fencing)

3. Dance/Walking

4. Crawling c. Assess the newborn for: 1. Presence or absence of each reflex. 2. Strength of each reflex. 3. Infant’s response to your assessment.

Absent.

Assessment XXII. CRY a. Frequency

Textbook Information

Possible Major Deviations and Complications

Infant Observation

Individual, 15-20 min q. 24 hrs to 2 hrs q. 24 hrs. Lusty, strong. Moderate pitch.

Unconsolable

b. Pitch XXIII. PERSONALITY AND BEHAVIOR a. Response to handling b. Reactions to environment

High pitch. Weak or absent.

Touch, massaging, warmth--> soothing Low pitch voice--> relaxation. Responds with quietness and increased alertness and cuddling, voice. Turns head and focuses when interested. Coordinates body movement to parent’s voice and body movement. Variations in interest/ hunger. Usually feeds well within 24 hrs. Wakeful periods about q. 3-4 hours. Unconsolable

c. Parent-infant interaction

No focus on person handling.

d. Eating-Sleeping patterns

Lethargy

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