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 limp Asymmetry of movement Persistent tremor, twitching To return to Table of Contents

Vital Signs
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

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 expected findings
Asymmetrical 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 consider
Varies 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 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)

To return to Table of Contents.

Skin
Expected findings
Skin 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 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 part Skin 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 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

To return to Table of Contents

Head
Expected findings
Anterior 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 variations
Caput 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

Eyes
Expected findings
Slate 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 variations
Edematous eyelids

Uncoordinated movements

May focus for a few seconds

Signs of potential distress or deviations from expected findings

Discharges 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

Ears
Expected findings
Pinna top on horizontal line with outer canthus of eye

Loud noise elicits Startle Reflex Flexible pinna with cartilage present

Common variations
Skin tags on or around ears

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

Clefts present Malformations Cartilage absent To return to Table of Contents

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

Signs of potential distress or deviations from expected findings
Choanal atresia and discharge Malformation Nasal 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 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 variations
Epstein's pearls on ridges of gums

Signs of potential distress or deviations from expected findings
Cleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete Protruding tongue Candida Albicans

Diminished tongue movement Percocious teeth

Neck
Expected findings
Short 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 findings
Torticollis-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 To return to Table of Contents.

Chest

Expected findings
Evident 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 findings
Asymmetrical chest movements Sternum depressed Marked retractions Absent breast tissue Flattened chest Supernumerary nipples Nipples widely spaced Bowel sounds auscultated

Abdomen
Expected findings
Dome-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 variations
Small umbilical hernia

Signs of potential distress or deviations from expected findings
Bowel sounds absent Peristaltic waves visible Abdominal distention Palpable masses Scaphoid-shaped abdomen Omphalocele Base of cord with redness or drainage Cord with two vessels To return to Table of Contents.

Back and Rectum

Expected findings
Intact spine without masses or openings Trunk incurvature reflex Patent anal opening "Wink reflex" present

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

To return to Table of Contents.

Back and Rectum

Expected findings
Intact spine without masses or openings Trunk incurvature reflex Patent anal opening "Wink reflex" present

Signs of potential distress or deviations from expected findings
Limitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cyst To return to Table of Contents.

Extremities
Expected findings
Maintains 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 findings
Unequal 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

To return to Table of Contents.

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 jerking Paralysis 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.edu Copyright 1996 Duquesne University

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