NEWBORN ASSESSMENT

POSSIBLE MAJOR DEVIATIONS

ASSESSMENT NORMAL FINDINGS AND COMPLICATIONS
I. General Measurements
a. Age Term- start of 38th wk. – end of 42nd Preterm=before end of 37th week
week Post term= after end of 42nd week
b. Weight 6.5-6.75 lbs. <6lbs, >9lbs
c. Length 18-20.5 inches / 45-52.3cm.
d. Apgar Score 7-10 <7
II. Head Measurement
a. Shape Round symmetrical; may have
moldingoverriding sutures; slight
asymmetry.
b. Size in relation to body 33-35cm Microcephaly <32cm
2cm>chest circumference Hydrocephaly >4cm from chest
Cephalohematoma
c. Fontanels size, shape, Sutures- palpable Full bulging, large, depressed
consistency Slight pulsation Closed sutures
1. Anterior Soft
3-4cm long
2-3cm wide
Diamond shape
2. Posterior 1-2cm
Triangular
III. Eyes
a. Color Black iris, white sclera Jaundiced sclera
b. Movement Random, jerky, uneven. Focus Gross nystagmus
momentarily. Follows to midline Constant Strabismus
Doll’s eye
c. Reaction to Light Pupils equal in size, round and reactive Pupils unequal, restricted, dilated, fixed
to light. May turn toward soft light.
d. Tears Without or occasionally Discharge
e. Evidence of sight Focuses and follows by 15min of age.; Does not respond to light, focus of follow
reactive to light
f. Eyelids Size ang movement symmetric. Blink Does not respond to light, focus, or
reflez. Edema from prophylaxis. Eyes follow
on a parallel plane.
IV. Ears
a. Reaction to noise Startle reflex to loud noise. Attends to Absence of reaction.
sound. By 15min. of age may move
eyes in direction of sound. Responds to
 crooning by relaxation
b. Position Line drawn through inner and outer Low placement
canthi of eye comes to top notch of ear
(where it connects with
scalp.)symmetrical.
c.Patency Evidence of hearing. Reaction to noise.
V. Nose Midline
a. Mucus Clear Copius drainage
b. Patency Infants obligatory nose breathers. Cyanosis at rest.
Sneezing is common Flaring or nares.
c. Reflexes Dependent on state of wakefulness and
hunger.
1. Sucking
2. Swallow
3. Gag
VI. Mouth Symmetrical Mouth drawls to one side
Presence of gag and swallowing reflex
Hard and Soft palate intact
Epstein’s Pearls Clefts
VII. Neck
a. Length Short, thick, surrounded by skin folds Webbing
b. Mobility Head held midline. Free movement from Rigid
side to side. Full flexion and extension. Restricted movement
Cannot move head past shoulder. Head held at angle.
Without head control.
VIII. Chest
a. Size 1-2cm < head circumference <30 cm
30-33cm
b. Breast tissue 3-10mm breast nodule Lack of breast tissue
Nipple prominent
c. Characteristic shape Almost circular Bulging of chest
Barrel shaped. Retractions
Bowel sounds in chest
IX. Respirations
a. Rate 30-60/min Tachypnea >60/min
Bradypnea <25/min
b. Rhythm Shallow Labored breathing
Irregular when infant is awake
c. Breath sounds No sounds heard without stethoscope Grunting, rales, rhonchi, wheeze (with or
without stethoscope)
d. Muscular activity involved Bronchial. Loud, clear Apnea >15sec.
 Simultaneous rise and fall of chest and Subcostal and substernal retractions.
abdomen. Diaphragmatic and Flaring of nares. Chin tug.
abdominal breathing.
X. Pulse
a. Rate 120-160/min Persistent tachycardia - >170
180 with crying Bradycardia - <120
100/min if asleep
b. Rhythm May be irregular for brief periods Persistent irregular rhythm.
especially after crying
c. Peripheral Circulation Femoral pulses palpable, equal, strong. Weak or absent.
Sluggish peripheral circulation.
XI. Arms and Hands
a. Length Arms equal in length. Anelia phocomelia
Arms longer than legs.
b. Movements Spontaneous Limited movements. Asymmetry of
Full range of motion movements.
Tonicity
c. Muscle tone Generally flexed. Fist often clenched Asymmetric contour.
with thumb under finger. Poor tone/floppy
+scarf sign.
d. Fingers
1. Number Correct Absence of or additional.
Short
2. Webbing Without webbing Polydactyl
Syndactyl
e. Position Fists often clenched with thumb under Rigid flexion.
finger. Persistent fists
XII. Abdomen
a. Contour Rounded, protruding Abdominal distended scaphoid
b. Musculature Not fully developed. Bowel sounds Sounds in chest.
audible 1-2 hours after birth
XIII. Umbilical Cord
a. Number of vessels at birth 2 arteries
1 vein
b. Appearance Clear gelatin, odorless, drying Bleeding or oozing; drainage or redness
XIV. Genitourinary
a. Female Ambiguous genitals
1. Labia Usually edematous
a.size Covers labia minora Labia majora widely separated
b.appearance May have pigment. Minora prominent.
Symmetric in size
 2. Vaginal discharge Absence of vaginal orifice
Fecal discharge
a.color Smegma under labia. May be blood
tinged
b.type Mucoid/white
b. Male Ambiguous genitals
1. Testes in scrotum Palpable each side Undescended
Large. Rugge. Cremasteric Scrotum smooth.
2. Urethral meatus at end of Correct position Not at tip of penis
penis Prepuce covers glans. Adherent prepuce.
Not easily retractable.
c. Voidings
1. Color Clear, light yellow
2. Amount Well saturated diapers
3. Frequency By 24 hrs after delivery. At least 3-4
times/day
4. Specific gravity 1.008-1.010
XV. Rectum
a. Patency Good sphincter tone of anus. Good wink
reflex.
b. Stools Meconium by 24 hrs. after birth Failure to pass meconium
1. Number Depends on age of infant and type of Abdominal distention
2. Color feeding she is receiving. Diarrhea – curdy, green, large water ring,
3. Consistency forceful.
4. Frequency
XVI. Hips
a. Symmetry Gluteal folds even Congenital hip dysplasia.
b. Femur heads Intact
No protrusions
XVII. Back
a. Appearance Straight, easily flexed
b. Turns head from side to side in Yes Limitation of movement.
prone position Can raise head momentarily Pigmented nevus with tuft of hair located
at base of spine.
Spina bifida.
XVIII. Legs and Feet
a. Appearance May appear to have bowed legs
b. Warmth Equal Different temperatures
c. Length Legs of equal length. Shorter than arms Unequal.
d. Movement Full ROM Hypermobility
 Lack of leg movement
e. Alignment Foot in straight line. May appear to turn Club foot.
in but easily rotated externally.
f. Muscle tone General flexion
g. Toes Feet flat. Well lined over 2/3 of surface
1. Number Correct Absent or excessive digits.
2. Webbing Without webbing Syndactyl
h. Position General flexion. Most often see legs Rigid of floppy posture
drawn up against abdomen
XIX. Skin
a. Color Generally pink. Acrocyanosis. May see Jaundice
some mottling. Cyanosis
Pallor or dark red.
b. Textures Smooth, soft. Flexible. May have dry Thinner or thicker texture.
peeling hands and feet. Without edema. Fish scale skin.
c. Birthmarks Teleangiectases Hemangiomas
Mongolian spots
Transient hyperpigmentation of areolas,
genitals.
d. Characteristics
1. Milia Distended sebaceous glands
particularly on nose and cheeks
2. Lanugo Over shoulder, pinniias, forehead, back Absent or excessive
3. Vernix Caseosa White, cheesy, odorless substance in Absent or excessive; yellow, green or
creases and folds foul odor.
4. Ecchymosis Petechiae over presenting part. Over other areas.
Ecchymosis from forceps
5. Hair Amount varies. Silky, growth pattern Fine, woolly, coarse, brittle, unusual
toward face and neck. growth pattern.
6. Nails Present, extended beyond fingertips Absence
7. Peeling Of hands and feet at about day 3. Generalized cracking and/ or peeling.
XX. Temperature
a. Normal 97.6-98.6°F axillary Hypothermia/Hyperthermia
b. Temperature regulatory Shivering mechanism undeveloped. Temperature not stabilized by 10hrs after
mechanism Brown fat. birth.
c. Heat Loss From evaporation, conduction, Swings of >2°F from one reading to the
convection, radiation. next.
XXI. Reflexes
a. Local
1. Blink Response to light stimulus. Tap on Continued blinking with repeated taps.
 forehead, bridge of nose, maxilla when
eyes open-blink first 4-5times.
2. Pupillary Response to light is equal. Round. Pupil Failure to respond. Response unequal.
constricts
3. Doll’s eyes When head is turned, eye movement
lags behind.
4. Rooting Turns head in direction of stimulus; Weak or absent.
opens mouth
5. Sucking/ swallowing Follows rooting. Takes hold, sucks and Weak or absent. Gagging, coughing, or
obtains fluids. vomiting with swallowing
6. Gag Safety reflex. Do not try to elicit.
7. Yawn Spontaneous
8. Grasp Finger curl around examiner’s finger.
Toes turn downward.
9. Babinski Hyperextension of all toes with Absent
dorsiflexion of big toe when one side of
sole is stroked from heel across ball of
foot to toe.
b. Generalized
1. Moro (startle) Symmetric abduction and extension of
arms.
Finger may fan with forefinger and
thumb forming a C. Arms then adduct in
embracing motion and return to relaxed
flexion.
2. Tonic neck (fencing) When head is turned to one side,
extremities on same side extend and on
opposite side flex.
3. Dance/ walking When held upright with one foot Asymmetry of stepping
touching a flat surface, will stimulate
walking. Will step alternately.
4. Crawling While on abdomen, will make crawling Absent.
movements with arms of legs.
c. Assess the newborn for:
1. Presence or absence of
each reflex.
2. Strength of each reflex
3. Infant’s response to your
assessment.
XXII. Cry
a. Frequency Individual 15-20min q 24 hrs to 2hrs q Unconsolable.

b. Pitch
XXIII. Personality and Behavior
a. Response to handling
b. Reactions to environment
c. Parent-infant interaction
d. Eating-Sleeping patterns
24hrs.
Lusty, strong, moderate pitch. High pitch.
Weak or absent
Touch, massaging, warmth -soothing
Low pitch voice- relaxation Unconsolable.
Responds with quietness and increased
alertness and cuddling voice.
Turns head and focuses when No focus on person handling
interested. Coordinates body movement
to parent’s voice and body movement
Variations in interest/ hunger. Usually Lethargy
feeds well within 24hrs. Wakeful periods
about q 3-4 hours.
APGAR SCORING