Felician College Department of Nursing and Health Management

Nursing 370

Neonatal Assessment Guide / Independent Study

Nursing 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 Student Name Grade

Assessment Areas Norms/Possible Alterations Description of

Findings
General Appearance Head disproportionately large
Briefly describe for the body, neck looks short,
(ex, dark hair, pink, flexed) chin rests on chest, prominent
abdomen, sloping shoulders,
narrow hips, rounded chest
Weight & Measurement
1. Weight – include range 2500-4000 g (5lb, 8oz., -8
& average lbs.13 oz.)

2. Height – include range 48 – 52 cm (18 -22 in.)

& average

3. Temperature

Axillary- 36.4 – 37.2C (97.5 – 99F)

Rectal (optional) 36.6-37.2C (97.8-99F) 36.8 C

(98.8F) desired
4. Head Circumferance 32-37cm (12.5-14.5 in.) 2cm
Greater than chest
circumference

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 5. Chest Circumference 32.5 cm, 1-2 cm less than head
Wider than it is long
Posture: briefly describe Body usually flexed, hands
may be tightly clenched, and
neck appears short because
Skin chin rests on chest.
1. Color Consistent with race.
European- pink-tinged, African
or Native American pale pink
with yellow tinge, Asian –pink
2. Texture to rosy red, yellow tinge.
Smooth, soft, flexible, may
have dray, peeling hands and
feet.
3. Turgor Elastic, returns to normal
shape after pinching

4. Pigmentation Clear, milia across bridge of

nose, forehead, or chin will
disappear within a few weeks

5. Jaundice

6. Normal Variations Café-au-lait spots (one or two)

Ex. Rashes, ET rash, Mongolian blue spots common
Mongolian spots, over dorsal area and buttocks
birthmarks, bruises, in dark-skinned infants
petechiae. Erythema toxicum
Telangiectatic nevi, rashes
Petechiae of head or neck
Head Assessment
1. General appearance 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)

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 4. Fontanels Palpation of juncture of cranial
A. Anterior bones
Fontanel 3-4cm long by 2-3 cm wide
diamond shaped
B. Posterior 1-2 cm at birth, triangle shaped
Fontanel

C. Pulsation? Slight pulsation

D. Bulging Moderate bulging noted with

crying, stooling; pulsations
with heartbeat
E. Sunken -

Hair
1. Texture Smooth with fine texture
variations, depends on ethnic
background
2. Distribution Scalp hair high over eyebrows
(Spanish-Mexican hairline
Face begins midforehead to neck)
1. Symmetry Symmetric movement of all
facial features, normal hairline,
eyebrows & eyelashes present
2. Spacing of features Eyes-ears at same level,
nostrils equal size, cheeks full,
and sucking pads present
3. Movement 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 dark-
skinned 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

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 5. Subconjunctival Chemical conjunctivitis,
hemorrhage? Subconjunctival hemorrhage

Nose
1. General appearance May appear flattened as a
result of birth process

2. Any sneezing? Sneezing common to clear

nasal passages

3. Occlude one nostril at Patent nares bilaterally ( nose

a time to check for breathers)
Choanal Atresia

Mouth
1. Symmetry? Symmetry of movement and
strength

2. Check for cleft palate Hard palate dome shaped,

uvula midline with symmetric
movement of soft palate, palate
3. Tongue intact
Tongue free moving in all
directions, midline
Ears
1. Position on head Top of ear (pinna) should be
relative to eyes parallel to the outer and inner
canthus of the eyes

2. Symmetry?

3. Preauricular skin tag?

4. Cartilage (does the ear

spring back when
folded)

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Neck
1. Appearance Short, straight, creased with
skin folds, posterior neck lacks
loose extra folds of skin
2. Mobility Moro reflex elicitable

Clavicles
1. Appearance &size Straight and intact

2. Expansion and/or Bilateral expansion

retractions

3. Breast tissue (measure Flat with symmetric nipples

and describe) Breast tissue diameter 5 cm or
more at term; average distance
between nipples 8 cm.

4. Auscultate breath Breath sounds are louder in

sounds infants, chest and axilla clear
on crying, air entry clear, rales
may indicate normal newborn
atelectasis
5. Describe general No inercostal, subcostal, or
breathing movements supraclavicular retractions

6. Respiratory rate (one 30- 60 bpm and predominately

minute) diaphragmatic

7. What can make the RR Brief periods of apnea with no

vary? color or heart rate changes in
healthy newborns

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Heart
1. Palpate for PMI & Usually lateral to
describe midclavicular line at third or
fourth intercostal space

2. Auscultate heart Regular rate and rhythm, no

sounds for one minute functional murmurs, 120-
& describe 160bpm

3. Any murmur? No functional murmurs

4. Any thrills? No thrills

Define a thrill. Vibration created by
turbulence of fluid passing
through an incompetent valve
5. What makes the HR Normal 120-160 bpm, if asleep
vary as low as 80 bpm, if crying up
to 180 bpm

Abdomen
1. Appearance Cylindric with some
protrusion, appears large in
relation to pelvis
2. Any Diastasis Recti? Common in infants of African
Americans

3. Palpate & describe Some laxness of abdominal

muscles

4. Umbiculus No protrusions of umbilicus

( but, common in African
descent)
5. Number of vessels Two arteries and one vein
present

6. Auscultate bowel Soft bowel sounds heard

sounds shortly after birth every 10-30
seconds

7. Palpate inguinal area No bulges along inguinal area

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 8. Describe voiding Emptied about 3 hours after
birth or time of birth,
inoffensive, mild odor
Genitals
Male
1. Penis Slender in appearance about
2.5 cm long 1 cm wide at birth

2. Placement of urinary Normal urinary orifice,

meatus urethral meatus at tip of penis

3. Scrotum Skin loose and hanging or tight

and small extensive rugae and
normal size, normal color
4. Testes Descended by birth, not
consistently found in scrotum
1.5-2 cm at birth
Female
1. General appearance Normal skin color are
pigmented in dark skinned
infants
2. Vaginal tag Disappears in a few weeks

3. Discharge Smegma under labia

Buttocks and Anus

1. Symmetry Symmetric

2. Pilonidal dimple -

3. Pattern of stools Meconium within 24-48 hours

of birth

Extremities & Trunk

1. General appearance Short and generally flexed,
extremities move
symmetrically through range
2. Symmetry of motion but lack full
extention
Symmetric

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 3. Complete a ROM & All joints move spontaneously;
desribe good muscle tone, of flexor
type, birth to 2 months

4. Arms (equal)? Equal in length

5. Assess & explain: Presence of extra digits on

Polydactyly either hands or feet. Should
not be present

Syndactyly Fusion (webbing) of fingers or

toes, should not be present

Simian crease Single palmar crease is

frequently present in children
with Down Syndrome
6. Spine C- shaped spine
Flat and straight when prone
Slight lumbar lordosis
Easily flexed and intact when
7. Hips palpated
No sign of instability
Hips abduct to more than 60
degrees
8. Legs Legs equal in length
Legs shorter than arms at birth

9. Feet Foot is in straight line

Positional clubfoot based on
Reflexes position in utero
1. Moro 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

2. Rooting 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;
3. Sucking disappears by 4-7 months
Sucking is adequate for nutritional
intake and meeting oral stimulation
needs – for 12 months
4. Palmar grasp Fingers grasp adult finger when palm is
stimulated and held momentarily-
lessens at 3- 4 months

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 Toes curl downward when sole of
5. Plantar grasp
foot is stimulated lessens by 8
months

6. Stepping When held upright and one foot

touching a flat surface, will step
alternately disappears at 4-8 weeks of
age
7. Babinski 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

8. Tonic neck 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
9. Trunk incurvation 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
2. Cry (pitch) Moderate tone and pitch,
strong and lusty

Sensory: What evidence is

there that the baby can or
cannot: Tracks moving object to midline, fixed focus
on objects at a distance about 10-20 in., may
1. See be difficult to evaluate in newborn, prefers
faces, geometric designs and black and white
to colors

2. Hear Attends to sounds, sudden or

loud noise elicits more reflex

3. Feel Accept physical contact,

responds to being handled

4. Taste (textbook only)

Can discriminate between
sweet and bitter flavors
5. Smell (textbook only)

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