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students will perform the following newborn assessment with the clinical instructor’s assistance during the clinical nursing experience. The purpose of this assessment is to increase the student’s knowledge about newborn physical assessment and to increase the student’s observational skills. • The clinical instructor will assign students the week before this assignment is due. • Students are required to complete the column entitled “Norms & Possible Alterations” prior to meeting with the clinical instructor for the hands-on clinical newborn assessment. • Students will describe fully what they see, hear, and feel during the clinical newborn assessment in the column entitled “Description of Findings” (this will be handed in the week following the experience to the clinical instructor). • References other than course textbooks must be listed. • Grading will be O =outstanding, S = satisfactory, or U = unsatisfactory Neonate’s Initials Assessment Areas General Appearance Briefly describe (ex, dark hair, pink, flexed) Student Name Norms/Possible Alterations Head disproportionately large for the body, neck looks short, chin rests on chest, prominent abdomen, sloping shoulders, narrow hips, rounded chest Grade Description of Findings
Weight & Measurement 1. Weight – include range 2500-4000 g (5lb, 8oz., -8 & average lbs.13 oz.) 2. Height – include range & average 3. Temperature AxillaryRectal (optional) 4. Head Circumferance 36.4 – 37.2C (97.5 – 99F) 36.6-37.2C (97.8-99F) 36.8 C (98.8F) desired 32-37cm (12.5-14.5 in.) 2cm Greater than chest circumference 48 – 52 cm (18 -22 in.)
5. Chest Circumference Posture: briefly describe Skin 1. Color
32.5 cm, 1-2 cm less than head Wider than it is long Body usually flexed, hands may be tightly clenched, and neck appears short because chin rests on chest. Consistent with race. European- pink-tinged, African or Native American pale pink with yellow tinge, Asian –pink to rosy red, yellow tinge. Smooth, soft, flexible, may have dray, peeling hands and feet. Elastic, returns to normal shape after pinching Clear, milia across bridge of nose, forehead, or chin will disappear within a few weeks
6. Normal Variations Ex. Rashes, ET rash, Mongolian spots, birthmarks, bruises, petechiae. Head Assessment 1. General appearance
Café-au-lait spots (one or two) Mongolian blue spots common over dorsal area and buttocks in dark-skinned infants Erythema toxicum Telangiectatic nevi, rashes Petechiae of head or neck
Round, symmetric, and moves easily from left to right and up and down, soft and pliable 2. Size (related to body) Greater than chest circumference, head one fourth of body size 3. Common Variations Molding Define and explain the Caput succedaneum (long differences between labor and birth disappears in 1 Caput Succedaneum & week, cephalhematoma(trauma Cephalhematoma. during birth, may persist up to 3 months)
4. Fontanels A. Anterior Fontanel B. Posterior Fontanel C. Pulsation? D. Bulging E. Sunken
Palpation of juncture of cranial bones 3-4cm long by 2-3 cm wide diamond shaped 1-2 cm at birth, triangle shaped Slight pulsation Moderate bulging noted with crying, stooling; pulsations with heartbeat -
Hair 1. Texture 2. Distribution Face 1. Symmetry 2. Spacing of features 3. Movement
Smooth with fine texture variations, depends on ethnic background Scalp hair high over eyebrows (Spanish-Mexican hairline begins midforehead to neck) Symmetric movement of all facial features, normal hairline, eyebrows & eyelashes present Eyes-ears at same level, nostrils equal size, cheeks full, and sucking pads present Makes facial grimaces Symmetric when resting and crying
Eyes 1. General placement and Bright and clear; even appearance placement, slight nystagmus (involuntary cyclic eye movement) 2. Color Blue-gray or slate-blue-gray Brown color at birth in darkskinned infants 3. Any tears? React to light by accommodation, light reflex demonstrated at birth or by 3 4. Pupils react to light? weeks of age
5. Subconjunctival hemorrhage? Nose 1. General appearance 2. Any sneezing? 3. Occlude one nostril at a time to check for Choanal Atresia Mouth 1. Symmetry? 2. Check for cleft palate 3. Tongue Ears 1. Position on head relative to eyes 2. Symmetry? 3. Preauricular skin tag? 4. Cartilage (does the ear spring back when folded)
Chemical conjunctivitis, Subconjunctival hemorrhage
May appear flattened as a result of birth process Sneezing common to clear nasal passages Patent nares bilaterally ( nose breathers)
Symmetry of movement and strength Hard palate dome shaped, uvula midline with symmetric movement of soft palate, palate intact Tongue free moving in all directions, midline Top of ear (pinna) should be parallel to the outer and inner canthus of the eyes
Neck 1. Appearance 2. Mobility Clavicles 1. Appearance &size
Short, straight, creased with skin folds, posterior neck lacks loose extra folds of skin Moro reflex elicitable
Straight and intact
2. Expansion and/or retractions
3. Breast tissue (measure and describe)
Flat with symmetric nipples Breast tissue diameter 5 cm or more at term; average distance between nipples 8 cm. Breath sounds are louder in infants, chest and axilla clear on crying, air entry clear, rales may indicate normal newborn atelectasis No inercostal, subcostal, or supraclavicular retractions
4. Auscultate breath sounds
5. Describe general breathing movements
6. Respiratory rate (one minute)
30- 60 bpm and predominately diaphragmatic
7. What can make the RR Brief periods of apnea with no vary? color or heart rate changes in healthy newborns
Heart 1. Palpate for PMI & describe 2. Auscultate heart sounds for one minute & describe 3. Any murmur?
Usually lateral to midclavicular line at third or fourth intercostal space Regular rate and rhythm, no functional murmurs, 120160bpm No functional murmurs
4. Any thrills? Define a thrill. 5. What makes the HR vary Abdomen 1. Appearance 2. Any Diastasis Recti? 3. Palpate & describe 4. Umbiculus 5. Number of vessels 6. Auscultate bowel sounds 7. Palpate inguinal area
No thrills Vibration created by turbulence of fluid passing through an incompetent valve Normal 120-160 bpm, if asleep as low as 80 bpm, if crying up to 180 bpm Cylindric with some protrusion, appears large in relation to pelvis Common in infants of African Americans Some laxness of abdominal muscles No protrusions of umbilicus ( but, common in African descent) Two arteries and one vein present Soft bowel sounds heard shortly after birth every 10-30 seconds No bulges along inguinal area
8. Describe voiding Genitals Male 1. Penis 2. Placement of urinary meatus 3. Scrotum 4. Testes Female 1. General appearance 2. Vaginal tag 3. Discharge Buttocks and Anus 1. Symmetry 2. Pilonidal dimple 3. Pattern of stools Extremities & Trunk 1. General appearance 2. Symmetry
Emptied about 3 hours after birth or time of birth, inoffensive, mild odor Slender in appearance about 2.5 cm long 1 cm wide at birth Normal urinary orifice, urethral meatus at tip of penis Skin loose and hanging or tight and small extensive rugae and normal size, normal color Descended by birth, not consistently found in scrotum 1.5-2 cm at birth Normal skin color are pigmented in dark skinned infants Disappears in a few weeks Smegma under labia Symmetric Meconium within 24-48 hours of birth Short and generally flexed, extremities move symmetrically through range of motion but lack full extention Symmetric
3. Complete a ROM & desribe
All joints move spontaneously; good muscle tone, of flexor type, birth to 2 months Equal in length
4. Arms (equal)?
5. Assess & explain: Polydactyly Syndactyly Simian crease 6. Spine
Presence of extra digits on either hands or feet. Should not be present Fusion (webbing) of fingers or toes, should not be present Single palmar crease is frequently present in children with Down Syndrome C- shaped spine Flat and straight when prone Slight lumbar lordosis Easily flexed and intact when palpated No sign of instability Hips abduct to more than 60 degrees Legs equal in length Legs shorter than arms at birth Foot is in straight line Positional clubfoot based on position in utero
Response to sudden movement or lout noise should be one of symmetric extension and abduction of arms with fingers extended thane return to normal relaxed flexion Turns in direction of stimulus to check or mouth; opens mouth and begins to suck rhythmically when finger or nipple is inserted into mouth; difficult to elicit after feeding; disappears by 4-7 months
8. Legs 9. Feet Reflexes 1. Moro 2. Rooting 3. Sucking 4. Palmar grasp
Sucking is adequate for nutritional intake and meeting oral stimulation needs – for 12 months
Fingers grasp adult finger when palm is stimulated and held momentarilylessens at 3- 4 months
5. Plantar grasp 6. Stepping 7. Babinski 8. Tonic neck 9. Trunk incurvation
Toes curl downward when sole of foot is stimulated lessens by 8 months When held upright and one foot touching a flat surface, will step alternately disappears at 4-8 weeks of age
Fanning and extension of all toes when one side of sole is stroked from heel upward across ball of foot, disappears at about 12 months Fencer postion – when head is turned to one side, extremities on same side extend and on opposite side flex, this may not be eveident during early neonal period disappears at 3-4 months In prone postion, stroking of spine causes pelvis to turn to stimuated side
Activity 1. Neonate cries when?
Cries vary in length from 3-7 minutes after consoling measures are used Moderate tone and pitch, strong and lusty
2. Cry (pitch)
Sensory: What evidence is there that the baby can or cannot: 1. See 2. Hear 3. Feel 4. Taste (textbook only) 5. Smell (textbook only)
Tracks moving object to midline, fixed focus on objects at a distance about 10-20 in., may be difficult to evaluate in newborn, prefers faces, geometric designs and black and white to colors
Attends to sounds, sudden or loud noise elicits more reflex Accept physical contact, responds to being handled Can discriminate between sweet and bitter flavors
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