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ASSESSING THE NEWBORN AND INFANT

Each newborn (birth to 30 days) arrives as a unique person with the energetic
desire to grow and learn. For approximately 40 weeks, the fetus has enjoyed a
warm, comfortable uterine environment with all needs met. At birth, he or she is
totally dependent on the caretaker. Because the newborn is unable to directly
communicate his or her needs, the nurse must learn assessment skills to identify
abnormal findings and promote a healthy environment.
Infants (111 months) have few communication skills. As they grow, they can smile,
frown, point, and even say no, but it will be several years before they can
communicate well enough to provide information during a patient history. Until then,
parents, siblings, and extended family are fine sources of information. Healthy
families usually raise healthy babies, so take every opportunity to offer education
and support during your assessment.
As you assess the infant, be sure to note if her or his physical development is
appropriate for her or his age and whether she or he is performing appropriate
developmental tasks for that age. Because growth and development are so rapid
during the first year of life, even the slightest developmental delay may signal an
underlying problem and warrant further investigation.
KEY PHYSICAL CHANGES INCLUDE:
Birth weight doubles by 6 months, triples by 12 months.
Height increases by 1 inch per month for first 6 months.
Fontanels are closing.
Lumbar curve develops with a lordosis once the infant begins to walk.
Drooling and teething occur.
Primitive reflexes disappear as the neurological system matures.
GROSS MOTOR CHANGES INCLUDE:
Rolls, crawls.
Pulls self up to sit.
Begins to walk.
Achieves head control.
FINE MOTOR CHANGES INCLUDE:
Grasps objects.
Puts objects in mouth.
Holds bottle.
Plays with toes.
Develops pincer grasp.
SENSORY CHANGES INCLUDE:
Develops better vision.
Follows objects with eyes.
Responds to sounds.
COMMUNICATION CHANGES INCLUDE:
Initially cries to convey needs.
Babbles.
Laughs.
Says three to five words by 12 months.
Begins to comprehend simple directions.
Imitates sounds.
SOCIALIZATION CHANGES INCLUDE:
Identifies parents.
Develops social smile.
Is aware of strange situations.
Has increasing difficulty separating from parents.
Becomes more fearful of strangers.
Begins to develop memory.
Shows emotions.

PERFORMING A GENERAL SURVEY


Before you perform your head-to-toe assessment of the newborn, ask yourself the
following questions and record your observations as baseline data.
Integumentary:
Are there any abrasions, lacerations,or birthmarks?
If so,describe them, and monitor for infection, bleeding, and trauma.
Head and Neck:
Are there masses on the head or neck?
These may indicate cephalohematoma or a fractured clavicle.
Eyes, Ears, Nose, Mouth, and Throat:
Are there exudates in the eyes?
If so, monitor for infection.
Is the baby blinking? Do his or her eyes follow an object within 8 inches?
Is there discharge from the ears, nose, and throat or nose congestion?
Fluid may be from delivery or could indicate infection.
Does the newborn respond to sound?
A reaction to sound should occur.
Respiratory Characteristics, Lungs, and Breathing:
Is the newborn congested or gasping for breath?
Fetal fluid that remains in the lungs can cause airway obstruction.
Cardiovascular Characteristics:
Is there cyanosis?
It may denote poor vascular profusion.
Is the newborn alert?
A newborn in difficulty will demonstrate irritability or be unarousable.
Temperature Regulation:
Is body temperature maintained?
Newborns are poor regulators of body temperature and are dependent on their
environment for warmth. Cold stress can cause respiratory distress.
Hepatic Regulation:
Does the newborn have jaundice?
Increasing jaundice denotes increased blood bilirubin, which can cause mental
deterioration if untreated.
Gastrointestinal Adaptation:
Has the newborn passed stool?
This proves that an anus is present.
Has she or he vomited?
Persistent vomiting suggests intestinal obstruction.
Genitourinary Adaptation:
Has the baby voided?
Voiding denotes kidney function.
Neurological Characteristics:
How are extremities moving?
Muscle tone should be symmetrical and not flaccid, extremities should be partially
flexed; hand mouth behavior should be evident; and when awake, newborn should
demonstrate random, purposeless, bilateral movements.
How does cry sound?
It should be loud, not high pitched or weak.
Endocrine Characteristics:
Is there evidence of fetal or maternal endocrine disease? Is the newborn jittery?
Maternal diabetes can cause severe hypoglycemia in the newborn. Low glucose
levels often manifest as jittery extremities.
Immunologic Adaptation:

Are defenses maintained?


Because the newborns immune response is not well established, protect portals of
entry (umbilical stump and breaks in skin) from infection.
Sleep and Rest Patterns:
What is the sleep pattern?
Newborns sleep up to 18 hours a day. The long sleep period promotes growth and
development. They should awaken for feedings every 3 to 4 hours.
Relationships, Psychosocial Profile, and Cultural/Ethnic Variations:
How are family members relating to the newborn?
The newborn is dependent on the family for its well-being. Parents should
demonstrate touching and holding of infant. Assist in the bonding process.
Responses may vary depending on cultural/ethnic variations.
PERFORMING A NEWBORN HEAD-TO-TOE PHYSICAL ASSESSMENT
AREA / SYSTEM / NORMAL FINDINGS
ABNORMAL FINDINGS / RATIONALE
1. POSTURE
Inspect posture.
Limp posture with extension of
Head and extremities flexed.
extremities: Associated with birth
injuries, anesthesia, acidosis,
hypoglycemia, hypothermia, or
congenital problems.
2. HEAD CIRCUMFERENCE
Measure head circumference.
33 to 35 cm.
Measure head circumference from
occiput to forehead.

3. CHEST CIRCUMFERENCE
Measure chest circumference.
Measure chest at nipple line.

4. ABDOMINAL CIRCUMFERENCE
Measure abdominal circumference.
Measure abdomen above the umbilicus.
5. LENGTH
Measure length.

6. WEIGHT
Weigh newborn.
Newborn weight is usually between
2500 and 4000 g (5 lb, 8 oz, and 8 lb,
13 oz).

Head circumference < 10% of normal:


Microcephaly related to congenital
malformation or infection.
Head circumference > 90% of normal:
Macrocephaly related to
hydrocephalus.

30.5 to 33 cm (2 to 3 cm less than


head).
Breast engorgement can affect
measurement.
Similar to chest measurement. Should
not be distended.

Crown to rump: 31 to 35 cm (about


equal to head circumference).
Head to heel: 45 to 55 cm (18 to 22
inches) at birth.
Molding can affect measurement.

7. TEMPERATURE
Take newborns temperature.
Axillary: 36.5 to 37.20C

Birth weights < 10 or > 90 percent are


abnormal.
Low birth weight (small for gestational
age): Associated with prematurity.
Macrosomic infant (large for
gestational age): Associated with
gestational diabetes in mother.
Hypothermia leads to cold stress.
Sepsis, environmental extremes, and
neurological problems can cause

hypothermia or hyperthermia.
8. PULSE
Auscultate heart rate.
Apical rate 120 to 160 BPM.
Rate increases with crying and
decreases with sleep.
9. RESPIRATIONS
Take newborns respirations.
30 to 60 breaths a minute; irregular.
Anesthesia during labor and delivery can
affect respirations.
10. BLOOD PRESSURE
Take newborns BP.
Systolic: 50 to 75 mm Hg.
Diastolic: 30 to 45 mm Hg.
Crying and moving increase systolic
pressure.
11. INTEGUMENTARY
Skin
Inspect skin, note, color, lesions.
Skin may be red, smooth, edematous,
mottled (cutis marmorata).
Hands and feet may be cyanotic
(acrocyanosis).
Physiological jaundice occurs after 24
hours.
Color may change with position
(harlequin sign).
Cheesy substance (vernix caseosa)
decreases as babys gestational age
increases to term.
Desquamation (peeling), ecchymosis,
and petechiae may occur from trauma
during delivery.
Milia (white papules) may occur on
face.
Miliaria or audamina (papules or
vesicles on face) are caused by
blocked sweat ducts.
Mongolian spots (bluish discoloration
in sacral area) are commonly seen in
African, Asian, Latin, and Native
American babies.
Telangiectatic nevi.
Flat hemangiomas (stork bites) may
be present at nape of neck.

Irregular rhythms such as bradycardia


(<100 BPM) and tachycardia (>160
BPM).
Most murmurs are not pathological
and disappear by age 6 months.
Respirations < 30 or > 60 breaths a
minute.
Periods of apnea > 15 seconds.

Low BP: May be caused by


hypovolemia.
Late clamping of umbilical cord can
increase BP because of expanded
blood volume from the placental
transfusion.

Persistent acrocyanosis: May indicate


thermoregulation problem or
hypoglycemia.
Extensive desquamation: Seen in
post-term baby
Pathological jaundice occurs within
first 24 hours.
Plethora: May indicate polycythemia.
Pallor: May indicate anemia,
hypothermia, shock, or sepsis.
Persistent ecchymosis or petechiae:
May be caused by thrombocytopenia,
sepsis, or congenital infection.
Poor turgor: Intrauterine growth
retardation or hypoglycemia.
Caf-au-lait spots (light brown spots):
If more than six or larger than 4 x 6
cm, may indicate neurofibromatosis
and can become precancerous with
age.
Nevus flammeus (port-wine stain):
Disfigures face and may be associated
with cerebral vascular malformation.
Giant hemangiomas and nevus
vasculosus (strawberry marks) tend
to trap platelets and lower circulating
platelet counts. They usually
disappear by age 5.
Reddish-blue round mass of blood
vessels (cavernous hemangioma)
must be monitored, and if size
increases, surgery may be necessary.
Erythema toxicum, a common
newborn rash of red macules and

Hair
Inspect hair, and note distribution.
Some lanugo is normal.
Nails
Inspect neonates nails.

12. HEENT
Head/Face
Inspect head and fontanels.
Gently palpate fontanels.
Inspect facial features and
movements.
Molding in birth canal may cause
asymmetry of face and skull and
should resolve within 1 week.
Anterior fontanel: Diamond shaped,
2.5 to 4 cm.
Posterior fontanel: Triangle shaped,
0.5 to 1 cm.
Soft and flat.
Symmetrical facial movements.

Neck
Inspect and palpate the neck.
Test tonic neck reflex.
Short neck.
Positive tonic reflex.
Able to hold head up with pull-to-sit
test.

Eyes
Inspect eyes, position, edema,
exudates, color of sclera, parallel
alignment, pupil size, and equality.
Test corneal/blink reflex.
Test red light reflex.
Eyes may be edematous after vaginal

papules, usually disappears in 1 week.


Bullae or pustules: May indicate
infections such as syphilis or
staphylococcus.
Thin, translucent skin and vernix
caseosa are signs of prematurity.
Genetic disorders may cause extra
skin folds.
Abundant lanugo is a sign of
prematurity.
Genetic disorders may cause
abnormal hair distribution unrelated to
gestational age.
Long nails are seen in post-term
babies.
Fused sutures.
Large fontanels: Associated with
hydrocephaly, osteogenesis
imperfecta, congenital
hypothyroidism.
Small fontanels: Associated with
microcephaly.
Bulging fontanels: May indicate
increased intracranial pressure.
Depressed fontanels: Associated with
dehydration.
Craniosynostosis (premature closure
of the sutures).
Cephalohematoma (hematoma
between periosteum and skull with
unilateral swelling).
Most uncomplicated
cephalohematomas totally resolve
within 2 weeks to 3 months.
Caput succedaneum (edema of soft
scalp tissue from birth trauma)
decreases gradually in several days.
Asymmetrical facial movements: May
result from damage to facial nerve
during forceps delivery.
Absent tonic reflex: Erbs palsy if
unilateral or dislocation of cervical
spine or fractured clavicle.
Head lag with pull-to-sit test: Muscle
weakness.
Torticollis (wry neck).

Subconjunctival hemorrhage: Trauma


during delivery.
Brushfield spots (speckling of iris),
epicanthal fold, and Mongolian slant:
Down syndrome.

delivery.
Eyes equal and symmetrical.
Blue-gray or brown iris; white or
bluish-white sclera.
Antimongolian slant; Mongolian slant
seen in Asian infants.
Positive red light reflex.
Positive blink reflex.
Positive corneal reflex.
No tears (tear production begins by 2
months).
Positive fixation on close objects.
Positive pupillary reaction to light.
Strabismus and searching nystagmus
caused by immature muscular control.
** Avoid bright light because it will cause
the newborn to avoid opening her or
his eyes and make assessment
difficult.

Ears
Inspect shape, position, and drainage.
Test hearing.

Pinna flexible, without deformity,

aligns with external canthus of eyes.


Positive startle reflex.
Nose
Inspect nares.
Nares patent.
Small amount of thin white mucus.
Nose may be flattened and bruised
from birth.
Mouth/Throat
Inspect mucous membranes, lips,
tongue, and palate.
Test sucking, rooting, gag, extrusion
and swallowing reflexes.
Mucous membranes pink and moist.
Frenulum of tongue and lip intact.
Palate intact, uvula midline.
Strong sucking reflex, positive
rooting, gag, extrusion, and
swallowing reflexes.
Minimal saliva.
Strong cry.
Natal teeth may be benign or
associated with congenital defects.
** Natal teeth must be removed by a
specialist because they usually fall out
and can cause choking.

Small white, pearl-like epithelial cysts


on the palate (Epsteins pearls),

Absent red light reflex: May indicate


congenital cataract.
Ptosis: Neuromuscular weakness.
Sun-setting (crescent of sclera over
iris caused by retraction of upper lid):
Hydrocephalus.
Yellow sclera: Jaundice.
Blue sclera: Osteogenesis imperfecta.
Persistent nystagmus, absent blink
reflex, inability to follow objects: May
indicate vision problem, such as
blindness.
Dilated or fixed pupil: May indicate
anoxia or neurological damage.
Chemical conjunctivitis from eye
prophylaxis may occur during first 24
hours.

Low-set ears: Down syndrome.


Absent startle reflex: Possible hearing
problem.

Because infants are obligatory nose


breathers, large amounts of mucus
drainage may obstruct nostrils and
cause respiratory difficulty.
Nasal flaring: Sign of distress.

Cyanotic mucous membranes:


Hypoxia.
Candida albicans (thrush): Contracted
during vaginal delivery.
Weak sucking, swallowing reflex: May
be caused by maternal anesthesia or
perinatal asphyxia.
Opening in palate or lips: Cleft palate
or lip. Any opening is abnormal. A
series of surgical interventions will be
necessary.
Weak cry: May indicate neuromuscular
problem, hypotonia, and prematurity.

ALERT
The ears and kidneys develop at the same
time in utero, so malformed ears may be
accompanied by renal problems.

disappear within a few weeks.


13. CHEST
Inspect shape, symmetry, and chest
excursion.
Inspect breast size, drainage.
Anteroposterior:lateral (1:1).
Equal chest excursion.
Breast engorgement.
Clear or milky liquid from nipples
(witchs milk) develops from
maternal hormones in utero.
Supernumerary nipples are a benign
finding.
14. RESPIRATORY
Auscultate breath sounds.
Lungs clear, bronchial to
bronchovesicular breath sounds
audible.
Cough reflex absent at birth, but
present 1 to 2 days later.
Scattered crackles a few hours after
birth.
15. CARDIAC
Auscultate heart sounds.
S1, S2, normal rhythm with
respiratory variations.
PMI fourth left intercostal space
midcostal line.
** Quiet but clearly audible murmurs
occur in 30 percent of newborns but
should disappear in 2 days.
16. ABDOMEN
Inspect abdomen and umbilical cord.
Note hernias or diastasis recti.
Gently palpate abdomen and femoral
pulse.
Auscultate bowel sounds.
Abdomen round.
Positive bowel sounds.
Liver edge palpable 2 to 3 cm.
Tip of spleen, kidneys palpable.
Cord bluish white with two arteries
and one vein.
Positive femoral pulses.
Umbilical hernias and diastasis recti
(separation of rectus muscles) more
common in African American infants
and often resolve within a year.
17. RECTUM
Inspect anus.
Anus patent.
Passage of meconium stool within 48
hours.
Positive anal reflex (anal wink).

Cleft lip or palate will cause newborn to


have difficulty with feeding

Funnel chest (pectus excavatum):


Congenital anomaly.
Pigeon chest (pectus carinatum):
Obstructed respiration in infancy.
Asymmetrical excursion, retraction:
Respiratory distress.
Red, firm nipples.

Persistent crackles, wheezes, stridor,


grunting, paradoxical breathing,
decreased breath sounds, prolonged
periods of apnea (>15 to 20 sec) are
signs of respiratory problems.

Dextrocardia (heart on right side).


Cardiomegaly: Displaced point of
maximal impulse (PMI).
Murmurs are often heard at base or
along left sternal border, and are
usually benign, but need to be
evaluated to rule out cardiac disorder.
Thrills.

Abdominal distension, ascites,


distended veins: May indicate portal
hypertension.
Green umbilical cord: May indicate
infection.
Absence of umbilical vessels:
Associated with heart and kidney
malformations.

Anal fissures or fistulas.


No stools: May indicate malformation
in gastrointestinal (GI) tract.

ALERT:

18. FEMALE GENITALIA


Inspect genitalia. Place thumbs on
either side of labia and gently
separate tissues to visualize
perineum.
Note presence of clitoris, vagina, and
hymen.
Urination within 24 hours.
Urinary meatus is midline and an
uninterrupted stream is noted on
voiding.
Labia majora and minora may be
edematous.
Blood-tinged vaginal fluid may be
noted (pseudomenstruation).
19. MALE GENITALIA
Inspect penis and note position of
urinary meatus.
Retract foreskin.
Palpate scrotum, and note
undescended testicle if present.
Urination within 24 hours.
Foreskin retracts.
Urethral opening at tip of penis.
Scrotum edematous.
Smegma.
Palpable testes.
20. MUSCULOSKELETAL
Inspect extremities, and note number
of digits and deformities.
Inspect spine, and note shape.
Inspect gluteal folds.
Perform Barlow-Ortolani maneuvers.
10 fingers and 10 toes.
Full ROM.
No clicks in joints.
Equal gluteal folds.
C curve of spine, no dimpling.
When arms and legs are extended:
Muscles symmetrical and with equal
muscle tone.
Arms and legs symmetrical in size and
movement.
Hands held as fists until after 1
month, when grasp becomes strong
and equal.
Position in utero may affect
appearance.
21. NEUROLOGICAL
Test the newborns reflexes.
Positive newborn reflexes.
Positive knee reflex.

Imperforate anus (absent anus)


requires immediate surgical repair.

Fused labia or absent vaginal opening.


Ambiguous genitalia.
Meconium from vaginal opening.
Inability to urinate within 24 hours.

ALERT:
A newborn clitoris larger than 0.5 cm
is abnormal.

Hypospadias (urethral opening on


ventral surface of penis).
Epispadias (urethral opening on dorsal
side of penis).
Chordee (ventrally curved penis).
Hydrocele (fluid in scrotum).
Inability to urinate within 24 hours.
Inability to retract foreskin.
Undescended testicles.
Inguinal hernia.
Ambiguous genitalia.
Meconium from scrotum.
Polydactyly: Extra digits.
Syndactyly: Webbed digits.
Phocomelia: Hands and feet attached
close to chest.
Hemimelia: Absence of distal part of
extremity.
Talipes (clubfoot): Foot permanently
twisted out of shape.
Severe bowing of legs is abnormal.
Unequal gluteal folds and positive
Barlow-Ortolani maneuver: Associated
with congenital hip dislocation.
Requires immediate referral.
Decreased ROM and muscle tone.
Swelling, crepitus, neck tenderness:
Possible broken clavicle.
Simian (transverse palmar) creases:
Down syndrome.

Hypotonia: Floppy, limp extremities.


Paralysis.
Marked head lag.
Tremors.

Asymmetrical posture.
Hypertonia: Tightly flexed arms and
stiffly extended legs with quivering.
Opisthotonic posture: Arched back.
Dimpling of spine, tuft of hair: May
indicate spina bifida or pilonidal cyst.

TESTING REFLEXES
Infant reflexes are often present at birth and occur because the neurological system
is immature. Many of these reflexes disappear as the neurological system develops.
Reflexes which are critical for infants survival:
1. Rooting Reflex
2. Sucking Reflex
3. Swallowing Reflex
Protective reflexes that lasts throughout life:
1. Blink or corneal Reflex
2. Papillary Reaction Reflex
3. Sneezing Reflex
4. Gag Reflex
5. Cough Reflex
6. Yawn Reflex
NEWBORN/INFANT REFLEXES
REFLEX / TECHNIQUE / NORMAL
ABNORMAL RESPONSE
RESPONSE
1. MORO
Present at birth and lasts 1 to 4
Premature or ill infants may have
months
sluggish response.
Technique: Startle infant by suddenly Positive response beyond 6 months
jarring bassinet or with infant in
indicates neurological problem.
Asymmetrical response may be
semisitting position, let head drop
caused by injury to clavicle, humerus,
back slightly.
Quickly abducts and extend arms and
or brachial plexus during delivery.
legs symmetrically.
Makes C with index finger and
thumb. Legs flex up against trunk.
2. STARTLE
Present at birth and lasts 4 months
Same as Moro.
Technique: Startle infant by making
loud noise.
Hands clenched, arms abducted,
flexion at elbow.
3. TONIC NECK
Present between birth and 6 weeks;
Response after 6 months may indicate
disappears at 4 to 6 months.
cerebral palsy.
Technique: With infant supine, rotate
head to one side so that chin is over
shoulder.
Infant assumes fencing position,
with arm and leg extended in
direction to which head was turned.
4. PALMAR GRASP
Present at birth; disappears at 3 to 4
Negative grasp seen with hypotonia or
months.
prenatal asphyxia.
Technique: Place object or finger in
palm of infants hand.

Infant grasps object tightly. If he or


she grasps your fingers with both
hands, infant can be pulled to a sitting
position.
5. PLANTAR GRASP
Present at birth; disappears at 3 to 4
months.
Technique: Place thumb firmly against
ball of infants foot.
Toes flex tightly downward in a
grasping motion.
6. BABINSKI
Present at birth; disappears at 1 year.
Technique: Stroke lateral surface of
sole of infants foot.
Toes should fan.
7. STEPPING OR DANCING
Present at birth; disappears at 3 to 4
weeks.
Technique: Hold infant upright with
her or his feet touching a flat surface.
Infant steps up and down in place.
8. ROOTING
Present at birth; disappears at 3 to 6
months.
Technique: Brush cheek near corner of
mouth.
Infant turns head in direction of
stimulus and opens mouth.
9. SUCKING
Present at birth; disappears at 10 to
12 months.
Technique: Touch lips.
Sucking motion occurs.
Dont check for rooting or sucking
responses immediately after a feeding
they will be difficult to elicit.
10. SWALLOWING
Present at birth and lasts throughout
life.
Technique: Automatically follows
sucking response during feeding.
Sucking and swallowing should occur
without coughing, gagging, or
vomiting.
11. EXTRUSION
Present at birth and lasts 3 to 4
months.
Technique: Touch tip of tongue.
Tongue protrudes outward.
12. GLABELLAR
Present at birth.
Technique: Tap on forehead.
Newborn blinks for first few taps.
13. CRAWLING
Present at birth; disappears at 6

Negative grasp seen with hypotonia or


spinal cord injury.

Diminished response associated with


neurological problem.

Poor response caused by hypotonia.

Prematurity or neurological problem


may cause weak or absent response.

Weak or absent response associated


with prematurity or neurological
defect.

Weak or absent response associated


with prematurity or neurological
problem.

Absence may indicate neurological


problem.
Continued extrusion of large tongue
associated with Down syndrome.

Persistent blinking with repeated taps


indicates extrapyramidal problem.

weeks.
Technique: Place infant on abdomen.
Newborn attempts to crawl.
14. CROSSED EXTENSION
Present at birth; disappears at 2
months.
Technique: Infant supine with leg
extended. Stimulate foot.
Flexion, adduction then extension of
opposite leg.
15. PULL-TO-SIT
Present at birth.
Technique: Pull infant to sitting
position.
Head lags as infant is pulled to sitting
position, but then infant is able to
hold up head temporarily.
16. TRUNK INCURVATION
Present at birth; disappears in a few
days to 4 weeks.
Technique: With infant prone, run
finger down either side of spine.
Flexion of trunk with hip moving
toward stimulated side.
17. MAGNET
Present at birth.
Technique: With infant supine, flex leg
and apply pressure to soles of feet.
Extends legs against pressure.

Peripheral nerve damage causes weak


response.
Spinal cord lesion causes absent
response.

Inability to hold up head suggests


prematurity or hypotonia.

Absent response indicates


neurological or spinal cord problem.

Breech birth may diminish reflex.


Absent response caused by spinal
cord problem.