ASSESSING THE AVERAGE NEWBORN Weight

Length  Normal range: 2.5-3.5 kgs

 Infants are weighed laying or sitting on an infant scale
 Normal range: 19-20inches (about 50cm)
 Because diapers can be very heavy in proportion to total body weight,
 Until they can stand securely (at approximately age 2 years), the most
weigh infants nude
accurate method for obtaining a length measurement for infants is
 Always keep a protective hand over an infant on an infant scale
the recumbent measuring board
(hovering but not touching), as infants squirm readily and there is
 Align the infant’s head snugly against the top bar of the frame and
danger of them falling
ask an assistant to secure it there
 Always cover scales with scale paper before weighing to prevent
 Straighten the infant’s body
spread of infection from one child to another
 Hold the infant’s feet in a vertical position. Bring the foot board up
snugly against the bottom of the foot/ PHYSIOLOGICAL CHANGES
 If an examining table is used, mark the spots at the top of the child’s
Step in-Place Reflex
head and bottom of feet and then measure between the marks.
 Plot height measurement on a standard graph.  Feet touching hard surface, baby will take few quick, alternating
steps
Head Circumference
 Disappears by 3 months of age
 Normal range: 35cm (13 ¾ inches)  In 4 months, baby can bear good portion of their body weight
 Measured at birth and routinely physical assessment until 1year of
Placing Reflex
age
 Made by placing a tape measure around an infant’s head just above  Similar to step-in reflex
the eyebrows and around the most prominent portion of the back of  Elicited by touching anterior surface of the lower part of a newborn’s
the head, the occipital prominence leg against a hard surface
Temperature Plantar Reflex
 Normal range: 36.1-37 C  Sole of the baby’s foot touches an object, toes grasp in the same
Chest Circumference manner as the fingers
 Disappears at about 8-9 months of age
 Normal range: 30-33cm (12-13 inches)
Tonic Neck Reflex
 Not done routinely, but only when the specific pathology warrants
 Chest circumference measured at the nipple line  Also called a boxer or fencing reflex
 Abdominal circumference measured at the level of the umbilicus  Heads usually turn to one side when sleeping
Heart Rate  Stimulate eye coordination

Moro Reflex
 Normal range: 120-180 bpm

Respiratory Rate  Can be initiated by startling the newborn with a loud noise
 Strong for the first 8 weeks of life then fades by the end of 4-5 months
 Normal range: 40-60 bpm of age

BABYGIRL
Blink Reflex  This is the loss of heat from a newborn’s wet skin to the surrounding
air
 To protect the eye from any object coming near by rapid eyelid
 Newborns lose heat by evaporation after delivery or after a bath
closure
Radiation
Rooting Reflex
 This is the loss of heat from a newborn’s skin to distant cold objects
 If the cheek is brushed or stroked near the corner of the mouth, the
newborn will turn the head in that direction helps a newborn find food APGAR
 Disappears at about 6 weeks of life
APGAR
Sucking Reflex
 Appearance, Pulse, Grimace, Activity, Respiration
 When a newborn’s lips are touched, baby makes a sucking motion  A standardized evaluation of the newborn’s condition
 Helps a newborn find food  Done at 1 minute after birth to determine the general condition
 To detect the cardiorespiratory function of the newborn and then 5
Swallowing Reflex
minutes to determine how well the newborn is adjusting to
 Food that reaches the posterior portion of the tongue is automatically extrauterine life and his adjustments to the new environment
swallowed
Heart Rate
 Gag, cough and sneeze reflexes maintain a clear airway
 0: absent
Extrusion Reflex
 1: < 100 bpm
 Prevents the swallowing of inedible substances  2: > 100 bpm
 Extrusion of any substance that is placed on the anterior portion of
Respiratory Effort
the tongue
 0: no spontaneous respiration
Palmar Gag Reflex
 1: minimal response (grimace) to suction or gentle slap on soles
 Newborns grasp an object in their palm by closing their fingers on i  2: responds promptly to suction or gently slap the sole with cry or
active movement
HEAT LOSS
Color
Convection
 0: pallor/cyanosis
 This is the loos of heat from the newborn’s skin to the surrounding  1: bluish extremities (acrocyanosis)
air  2: pinkish (for fair-skinned) or absence of cyanosis (for dark-
 Experts recommended temperatures between 68 and 72 degrees F, skinned); pink mucous membranes
which is the equivalent of 20 to 22 degrees C
Interpretations
Conduction
 0-3: the newborn is in serious danger and requires immediate
 This is the loss of heat when a newborn lies on a cold surface resuscitation
 4-6: condition guarded and may need more extensive clearing of the
Evaporation
airway; may need oxygenation and suctioning

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  7-10: newborn is in best possible health, no signs of immediate  RR is more than 60 bpm (tachypnea)
distress, needs only admission care and no special care  Cyanosis
 Apnea
Respiratory Distress
 Chest indrawings
 Sliverman & Anderson Index  Nasal flaring
 Rapid breathing
Chest Movement  Shallow breathing
 Shortness of breath and grunting, stridor or wheeze sounds
 0: synchronized respirations
while breathing
 1: lag on inspiration
 2: seesaw respirations SKIN COLOR
Intercostal Retraction Cyanosis
 0: none  Generalized mottling of the skin is common in newborns
 1: just visible  Lips, hands and feet are likely to appear blue fro acrocyanosis
 2: marked (immature peripheral circulation)
 Acrocyanosis is a normal finding for the first 24-48 hours after birth
Xiphoid Retracton
 Central cyanosis or cyanosis of the trunk indicated decreased
 0: none respiratory obstruction and respiratory or cardiac disease
 1: just visible  Mucus could obstruct the respiratory system resulting in sudden
 2: marked cyanosis and apnea
 Suctioning the mouth and nose relieves this
Nares Dilatation  Always suction the mouth before the nose to prevent triggering a
 0: none reflex gap
 1: minimal Hyperbilirubinemia
 2: marked
 Caused by the accumulation of excess bilirubin in the blood serum
Expiratory Grunt  Physiologic jaundice
 0: none o Average newborns appear yellow on the skin and sclera as
 1: audible by stethoscope a result of breakdown of fetal red blood cells
 2: audible by unaided ear o Heme – iron + protoporphyrin – indirect bilirubin (fat-
soluble)
Interpretation  Indirect bilirubin is converted by liver enzymes into direct bilirubin so
it can be excreted
 0: no respiratory distress
 Infants who are prone to extensive bruising are also prone to
 1-3: mild respiratory distress
jaundice
 4-6: moderate respiratory distress
 Cephalohematoma
 7-10: severe respiratory distress
o Collection of blood under the periosteum of the skull bone
Signs and Symptoms caused by pressure at birth
o Can also lead to jaundice

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  Intestinal obstruction  Fine, downy hair that covers a newborn’s shoulders, back and upper
o Results in the breakdown of bile into indirect bilirubin arms
o Early feeding and excretion of meconium prevents indirect  Evident on babies born 37039 weeks
bilirubin buildup  Rubbed away through natural friction
 Gone in 2 weeks
Pallor
Desquamation
 Paling of the skin
 Result of anemia or internal bleeding  A skin reaction to sudden change in environment (liquid-filled to air-
 This may be caused by filled)
o Excessive blood loss when the cord was cut  Drying of the skin
o Inadequate flow of blood from the cord into the infant at birth  Evident in palms and soles
o Fetal-maternal transfusion  Starts within 24 hours after birth
o Low iron stores of the mother  Special considerations
o Blood incompatibility in which a large number of red blood  Post-term newborns and those who have suffered intrauterine
cells were hemolyzed in utero malnutrition

Harlequin Sign Milia

 Cutaneous condition in which the newborn is characterized by
momentary red coloring in the half of the newborn’s body
 It is of no clinical significance
 It is due to the immature circulation of the newborn
 The odd color changes or fades if the infant’s position is changed or
kicks and cries vigorously
Vernix Caseosa
 White, cream cheese-like substance that serves as a skin lubricant
in utero
 Noticeable on a term newborn’s skin, at least in the skin folds, at birth
 Shows the color of the amniotic fluid
Erythema Toxicum
 Yellow vernix
o Implies that the amniotic fluid was yellow from bilirubin
 Green vernix
o Indicates that meconium was present in the amniotic fluid
 Nursing interventions
o Handle newborns with gloves to protect yourself from
exposure to this body fluid
o Never use harsh rubbing to wash away vernix
Lanugo
 Tiny white bumps that appear across a baby’s nose, chin or cheeks
 Common in newborns but can occur at any age
 Symptoms
o Most commonly seen on a baby’s nose, chin or cheeks, upper
trunk, limbs, gums or the roof of the mouth (Epstein pearls)
o Some babies also develop baby acne, often characterized by
small red bumps and pustules on the cheeks, chin and
forehead, which can occur with or without milia
 Causes
o Milia develop when tiny skin flakes become trapped in small
pockets near the surface of the skin
 Alsocalled Erythema Toxicum Neonatorun (ETN) or toxic erythema of
the newborn
 Is a common rash seen in full-tem newborns
 It usually appears in the first few days after birth and fades within a
week
 The rash can be on the baby’s face, chest, arms and legs but usually
won’t be on the palms or soles of the feet
 Its’ a blotchy red rash with small bumps that can be filled with fluid
 Although the fluid might look like pus, there is no infection

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Forceps Marks NURSING DIAGNOSIS

 Circular or linear contusion matching the rim of the forceps blade on 1. Risk for ineffective thermoregulation related to newborn’s transition
he infant’s cheek to extrauterine environment
 Occurs with normal forceps use 2. Risk for ineffective airway clearance related to presence of mucus in
 Disappears in 1-2 days (along with the accompanying edema) mouth and nose at birth
 Nursing interventions 3. Risk for infection related to newly clamped umbilical cord and
o Closely assess the face of the newborn with the marks exposure of eyes to vaginal secretions
(especially during a crying episode)
o Check if the infant’s mouth is symmetrical

Skin Turgor

 Like adult skin

 Feel resilient if the underlying tissue is well hydrated
 How
o Grasp a fold of the ski between thumb and fingers (evaluate
if it feels elastic)
o Assess that when released, skin should fall back to form a
smooth surface
o If severe dehydration, skin will not smooth out again but will
remain as an elevated ridge
 Poor turgor = poor hydration
 Malnutrition in utero
 Difficulty sucking at birth
 Metabolic disorder (adrenocortical insufficiency)

Caput Succedaneum

 Edema of scalp at the presenting part of the head

 Crosses suture line and gradually absorb
 Needs no treatment

Cephalhematoma

 Collection of blood between the periosteum of the skull bone and the
bone itself
 Usually occurs 24 hours after birth
 Swelling is severe and is well outlined as an egg shape
 Discolored
 Confined to an individual bond
 Takes weeks to be absorbed
 Indirect bilirubin leading to jaundice
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