ASSESSING NEWBORNS AND

INFANTS
NCM 101-HEALTH ASSESSMENT IN NURSING

REFERENCES:
Health Assessment in Nursing by Weber and Kelly
Kozier and Erb Fundamentals in Nursing
Maternal & Childhealth Nursing by Pilliteri
Handbook of Health Assessment by Weber
Prepared by: Vivian Cezar, RN
Topic Overview:
PROFILE OF THE NEWBORN
• Vital Statistics

GROWTH AND DEVELOPMENT

INITIAL HEALTH ASSESSMENT

• Subjective Data
• Objective Data (Physical Assessment)
• APGAR SCORE
• AOG (AGE OF GESTATION)
• NEWBORN REFLEXES

2
What is the Difference between a
Newborn and an Infant?

INFANT
28 DAYS – 1 YEAR

NEWBORN
0-28 DAYS

3
 VITAL STATISTICS OF A NEWBORN
PARAMETERS NORMAL RANGE VALUE

Weight 2.5 g to 4000 g (5 lbs. 8 oz. – 8 lbs 13 oz.)

Length 48 cm to 53 cm ( 19 to 21 inches)

Head circumference 32 cm to 37 cm (12.5 in. to 14.5 in.)

Chest Circumference 30 cm to 35 cm ( 12 in. to 14 in. )

Abdominal Circumference 32 cm ( 12.5 in.)

*Mid-arm Circumference 9 cm – 11 cm

4
5
 GROWTH AND
DEVELOPMENT OF THE
NEWBORN

6
PHYSICAL
DEVELOPMENT

7
PHYSICAL
DEVELOPMENT
A. CEPHALOCAUDAL B.
– head to toe PROXIMODISTAL
– central-
direction periphery

8
SKIN, HAIR, ■ Skin is smooth and thin
■ Vernix caseosa may be visible on
NAILS the skin
■ Sebaceous glands are active
because
of high levels of maternal androgen
■ downy hairs (lanugo)
■ Scalp hair-follicle growth phases
occur concurrently at birth but
are disrupted during early
infancy
■ Nails are usually present at birth

9
Head and ■ Head growth predominates during the fetal
period.
Neck ■ head circumference is greater (by 2 cm)
than that of the chest
■ CLAMPS (Coronal, Lamboidal, Anterior
fontanelle, Metopic, Posterior fontanelle,
Sagittal)
■ Skull is typically asymmetric
(plagiocephaly) because of molding that
occurs as the newborn passes throughthe
birth canal
■ Posterior fontanelle usually measures 1 to 2
cm at birth closes at 2 months.
■ Anterior fontanelle measures 4 to 6 cm at
birth and closes between 12 and18 months.
■ Neck is usually short during infancy (lengthening
at about age 3 or 4 years)

10
  Eye structure and function are not fully developed at
birth.
■ iris shows little pigment, and the pupils are small.

Eyes ■ The macula, which is absent at birth, develops at 4 months

and is mature by 8 months.
■ Pupillary reflex is poor at birth and improves at 5 months
of age.
■ The sclera is clear.
■ Peripheral vision is developed, but central vision is not.
■ The newborn is farsighted and has a visual acuity of
20/200.
■ 4 months, an infant can fixate on a singular object with
both eyes simultaneously (binocularity).
■ Tearing and voluntary control over eye muscles begin at 2
to 3 months;
■ 4 months, infants establish binocular vision and focus on a
single image with both eyes simultaneously & improves at
9 months
■ Newborns cannot distinguish between colors; this ability
develops by 8 months.

11
 ■ The inner ear develops during the first
Ears trimester of gestation.
■ hear loud sounds at 90 decibels and
react with the startle reflex
■ respond to low frequency sounds, such
as a heartbeat or a lullaby, by
decreasing crying and motor movement
■ the external auditory canal curves
upward and is short and straight
■ eustachian tube is wider, shorter, and
more horizontal, increasing the
possibility of infection rising from the
pharynx

12
 ■ Saliva is minimal at birth but drooling is
evident by 3 months because of the
Mouth, increased secretion of saliva (Drooling)
■ The development of both temporary
Throat, Nose, (deciduous) and permanent teeth begins in
utero.
and Sinus ■ Deciduous tooth eruption takes place
between the ages of 6 and 24 months
■ tonsils and adenoids are small in relation to
body size and hard to see at birth
■ pharynx is best seen when the newborn is
crying
■ Newborns are obligatory nose breathers and,
therefore, have significant distress when
their nasal passages are obstructed
■ The maxillary and ethmoid sinuses are
present at birth but they are small and
cannot be examined until they develop

13
Thorax and ■ Fetal lungs should be developed and the
alveoli should be collapsed.

Lungs ■ Immediately after birth, the lungs

aerate; blood flows through them more
vigorously, causing greater expansion
and relaxation of the pulmonary
arteries.
■ The decrease in pulmonary pressure
closes the foramen ovale, increasing
oxygen tension and closing the ductus
arteriosus.
■ The lungs continue to develop after
birth, and new alveoli form until about
8 years of age.

14
 ■ Ventral epidermal ridges (milk lines), which
Breasts run from the axilla to the medial thigh, are
present during gestation.
■ True breasts develop along the thoracic ridge;
the other breasts along the milk line atrophy.
■ Occasionally a supernumerary nipple persists
along the ridge track.
■ At birth, lactiferous ducts are present in the
nipple but there are no alveoli.
■ Newborn’s breasts may be temporarily
enlarged from the effects of maternal
estrogen, they are usually flat and remain so
until puberty

15
Heart ■ The foramen ovale closes within the first
hour because of the newly created low
pressure in the right side of the heart, and
the ductus arteriosus closes about 10 to
15 hours after birth.
■ murmur generally resolves within 24 to 48
hours after birth
■ pulse rate is usually between 120 and 160
beats/minute
■ The heart should be auscultated at
approximately the 4th intercostal margin
to the left of the mid-clavicular line.
■ The heart lays more horizontal in the
chest and may seem enlarged with
percussion.
■ Heart sounds are also more audible in the
newborn secondary to the thin
subcutaneous layer of skin on the
newborn.

16
Peripheral
Vascular System ■ The skin should appear pink and
well perfused.
■ The hands and feet may appear
blue at times (acrocyanosis),
which is normal, especially when
the newborn is cold.
■ Pulses should be audible at the
4th intercostal space. Pulses
should be felt in extremities,
assessing the radial, brachial,
and femoral pulses bilaterally.

17
 ■ UMBILICAL CORD is prominent in the newborn and
contains two arteries and one vein.

Abdomen ■ The umbilicus consists of two parts: The amniotic

portion is covered with a gel-like substance and
dries up and falls off within 2 weeks of life.
■ The cutaneous portion is covered with skin and
draws back to become flush with the abdominal
wall.
■ The abdomen of infants is cylindrical.
■ newborn’s liver is palpable at 0.5 to 2.5 cm below
the right costal margin, thereby occupying
proportionately more space than at any other time
after birth
■ Kidney development is not complete until 1 year of
age.
■ Bladder capacity increases with age; the bladder is
considered an abdominal organ in infants because
it is located between the symphysis pubis and the
umbilicus.

18
Genitalia ■ In male infants the testes develop
prenatally and drop into the scrotum
during month 8 of gestation.
■ Each testis measures about 1 cm wide
and 1.5 to 2 cm long.
■ At birth, female genitalia may be
engorged. Mucoid or bloody discharge
may be noted because of the influence
of maternal hormones.
■ The genitalia return to normal size in a
few weeks and remain small until
puberty.

19
 ■ Meconium is passed during the
first 24 hours of life, signifying
anal patency.
Anus, ■ Stools are passed by reflex, and
Rectum, and anal sphincter control is not
reached until 1.5 to 2 years of
Prostate age after the nerves supplying
the area have become fully
myelinated.
■ In boys, the prostate gland is
underdeveloped and not
palpable.

20
 ■ At birth the newborn should have full
range of motion (ROM) of all
extremities.
■ The feet should turn to the normal
position with ease by the examiner.

Musculoskeletal ■ The hips should also be checked for

dislocation and ease of movement by

System performing the Ortolani test and

Barlow’s sign
■ The spine has a single C-shaped curve at
birth.
■ By 3 to 4 months, the anterior curve in
the cervical region develops from the
infant raising its head when prone.

21
 ■ The neurologic system is not fully
developed at birth.
■ Motor control is maintained by
the spinal cord and medulla, and
Neurologic most actions in the newborn are
primitive reflexes.
System ■ Newborns have rudimentary
sensation. Any stimulus must be
strong to cause a reaction, and
the response is not localized.
■ Motor control develops in a head-
to neck to trunk-to-extremities
sequence

22
 MOTOR DEVELOPMENT
Gross Motor Fine Motor Socialization and
Month Play
Development Development Language
Enjoys watching
Keeps hands
face of primary
listed; able to
0-1 Largely reflex
follow object to X caregiver,
listening to
midline
soothing sounds
Makes cooing
Holds head up when Enjoys bright
2 prone
Has social smile sounds;
colored mobiles
differentiates cry
Spends time looking
Holds head and at hands or uses
Follows object past
3 chest up when
midline
Laughs out loud them as toy during
prone the month (hand
regard)

23
 MOTOR DEVELOPMENT
Gross Motor Fine Motor Socialization and
Month Play
Development Development Language

Grasp, stepping, tonic neck Needs space to

4 reflexes are fading x x turn

Turns front back; no longer

has head lag when pulled
Handles rattles
5 upright; bears partial x x well
weight on feet when held
upright

Enjoys bathtub
Turns both ways; moro May say vowel
6 reflex fading
Uses palmar grasp toys, rubber ring
sounds (oh-oh)
for teething

24
 MOTOR DEVELOPMENT
Gross Motor Fine Motor Socialization and
Month Play
Development Development Language
Reaches out in
anticipation of
being pick up; first Likes objects that
Transfers objects
7 tooth (central
hand to hand
Shows beginning are good for
incisor) erupts; sits transferring
unsteadily (still
needs support)
Has peak fear of Enjoys
Sits securely strangers (ability to manipulation,
8 without support x tell known from rattles and toys of
unknown people) different textures

Creeps or crawls Says first word Needs space for

9 (abdomen off floor) x (dada) creeping

25
 MOTOR DEVELOPMENT
Gross Motor Fine Motor Socialization
Month Play
Development Development and Language
Uses pincer grasp
Plays games likes
(thumb and finger)
10 Pulls self to standing
to pick up small x patty cake and peek
a boo
objects
Cruises (walks with
11 support)
x x cruises

Likes toys that fit

Holds cup and spoon inside each other
Stands alone; some Says two words
well; helps to dress (pots and pans);
12 infants take first
(pushes arm into
plus ma-ma and
nursesry rhymes;
step da-da
sleeve) will like pull toys as
soon as walking

26
 SENSORY PERCEPTION DEVELOPMENT

VISUAL: unfocused, ability to distinguish between colors is not developed

until approximately 8 months of age.

AUDITORY: can distinguish sounds and turn toward voices and other noises;
very familiar with their mother’s voice, and other sounds gradually gain
significance when associated with pleasure

OLFACTORY: Smell is fully developed at birth, and 2-week-old infants can

differentiate the smell of their mother’s milk and parents’ body odors.

TACTILE: Touch is well developed at birth, especially the lips and tongue.

27
 COGNITIVE AND LANGUAGE
DEVELOPMENT (PIAGET)
■ The sensorimotor stage, from birth to around 18 months:
– development of intellect and knowledge of the environment gained
through the senses.
– During this stage, development progresses from reflexive activity to
purposeful acts.
– At the completion of this stage, the infant achieves a sense of object
permanence (retains a mental image of an absent object; sees self as
separate from others).
– An emerging sense of body image parallels sensorimotor development.
– Crying is the first means of communication, and parents can usually
differentiate cries.

28
 COGNITIVE AND LANGUAGE
DEVELOPMENT (PIAGET)
■ Cooing begins by 1 to 2 months,
■ laughing and babbling by 3 to 4 months, and consonant sounds by 3 to 4
months.
■ The infant begins to imitate sounds by 6 months.
■ Combined syllables (“mama”) are vocalized by 8 months, and
■ the infant understands “no-no” by 9 months.
■ “Mama” and “dada” are said with meaning by 10 months, and the infant says
■ a total of 2 to 4 words with meaning by 12 months.

29
 MORAL DEVELOPMENT (KOLBERG)
■ Child moral development begins with the value and
belief system of the parents and the infant’s own
development of trust.
■ Parental discipline patterns may start with the young
infant in the form of interventions for crying behaviors.
■ Stern discipline and withholding love and affection may
affect infant moral development.
■ Love and affection are the building blocks of an infant’s
developing sense of trust.

30
PSYCHOSOCIAL DEVELOPMENT
(ERIKSON)
■ The crisis faced by an infant (birth to 1 year) is termed trust versus mistrust.
■ In this stage, the infant’s significant other is the “caretaking” person.
■ Developing a sense of trust in caregivers and the environment is a central
focus for an infant.
■ This sense of trust forms the foundation for all future psychosocial tasks.
■ The quality of the caregiver–child relationship is a crucial factor in the infant’s
development of trust.

31
PSYCHOSEXUAL DEVELOPMENT
(FREUD)
■ ORAL STAGE of development, from birth to 18 months,
the erogenous zone is the mouth, and sexual activity
takes the form of sucking, swallowing, chewing, and
biting.
■ In this stage, the infant meets the world by crying,
tasting, eating, and early vocalization; biting, to gain a
sense of having a hold on and having greater control of
the environment; and grasping and touching, to explore
texture variations in the environment.

32
 NORMAL INFANT NUTRITIONAL
REQUIREMENTS
■ Breast milk is the most desirable complete food for the first 6
months of a child’s life.
■ Iron-fortified formula is an acceptable alternative. Formula intake
varies per infant.
■ Most infants take 100-cal/kg body weight/day. This amount of
formula should be offered to the infant every 3 to 4 hours,
approximately four to six times a day.
■ Juices may be offered at 6 months of age.
■ Finger foods are introduced at 8 or 9 months.
■ Weaning from breast or bottle to cup should be gradual. The desire to
imitate at 8 to 9 months increases the success of weaning.

33
NORMAL INFANT SLEEP
REQUIREMENTS AND PATTERNS
■ Sleep patterns vary among infants.
■ During the first month, most infants sleep when not eating.
■ By 3 to 4 months, most infants sleep 9 to 11 hours at night.
■ By 12 months, mos infants take morning and afternoon naps.
■ Bedtime rituals should begin in infancy to prepare the infant for sleep
and prevent future sleep problems.
■ Because of the possibility of SIDS (sudden infant death syndrome),
caution parents to place their young infants to sleep in the supine
or side-lying position.

34
SUBJECTIVE DATA
(NURSING HEALTH HISTORY)

35
 ■ FOCUS QUESTIONS:

Interviewing  Prenatal History: Gravida? Para? EDC?;

Gestational Age? Maternal Hx? Risk Factors?
Parents Prenatal exposure to drugs? Complications?
Blood type? Maternal testing?
 Labor and delivery history: Date, time, type
of delivery? Prolonged labor? Narcotics? Time of
rupture of membranes? Intrapartum
Get a complete complications?
history of the mother  Delivery History: APGAR scores? Respiratory
effort? Resuscitation efforts? Medications?
before and during Procedures performed? Evidence of injury?
pregnancy Void? Stool?
 Social History: Parent interaction? Significant
others? Cultural variations? Typeof infant
feeding? Male circumcision requested?

36
OBJECTIVE DATA
(NEWBORN PHYSICAL EXAMINATION)

37
APGAR
SCORE
Assigned at 1-5
minutes after delivery.

38
 VITAL
SIGNS

Vital sign measurements

begin to change from
those present in
intrauterine life at the
moment of birth.

39
TEMPERATURE

40
 ■ The heart rate of a newborn
often remains slightly irregular
because of immaturity of the
cardiac regulatory center in the
medulla.

PULSE ■ Transient murmurs may result

from the incomplete closure of
fetal circulation shunts.
■ A newborn’s heart rate is always
determined by listening for an
apical heartbeat for a full
minute, rather than assessing a
pulse in an extremity.

41
 ■ Respiratory depth, rate, and
rhythm are likely to be irregular,
and short periods of apnea
(without cyanosis) which last less
than 15 seconds, sometimes
called periodic respirations, are
normal.
RESPIRATION ■ Respiratory rate can be observed
mosteasily by watching the
movement of a newborn’s
abdomen, because breathing
primarily involves the use of the
diaphragm and abdominal
muscles.

42
BLOOD
PRESSURE ■ The blood pressure of a newborn
is approximately 80/46 mm Hg at
birth.
■ By the 10th day, it rises to about
100/50 mm Hg.
■ Because measurement of blood
pressure in a newborn is
somewhat inaccurate, it is not
routinely measured unless A
cardiac anomaly is suspected.

43
MEASUREMENTS

44
 ASSESSMENT
OF
GESTATIONAL
AGE (AOG)

 4 HOURS AFTER BIRTH

 BALLARD SCALE

45
46
NEWBORN REFLEXES

47
Blink Reflex How to elicit/How to observe
It may be elicited by shining a strong
light such as a flashlight or an
otoscope light on an eye

Normal Finding
A sudden movement toward the eye
sometimes can
elicit the blink reflex

48
Rooting How to elicit/How to observe
Reflex brushed or stroked near the
corner of the mouth

Normal Finding
a newborn infant will turn the
head in that direction

Disappearance of Reflex
The rooting reflex disappears by 3–
4 months.

49
Sucking How to elicit/How to observe

Reflex newborn’s lips are touched

Normal Finding
The baby makes a sucking
motion

This reflex disappears at 10–12 months.

50
Swallowing How to elicit/How to observe
Food that reaches the
Reflex posterior portion of the
tongue is automatically
swallowed

Normal Finding
normal swallowing does not
keep the pharynx free of
obstructing mucus

51
Palmar Grasp How to elicit/How to observe
Newborns grasp an object placed in
Reflex their palm by closing their fingers
on it

Normal Finding
newborns grasp so strongly

Disappearance of Reflex
This reflex disappears at 3–4 months.

52
STEPPING How to elicit/How to observe

REFLEX Newborns who are held in a

vertical position with their feet
touching a hard surface

Normal Finding

Will take a few quick, alternating steps

Disappearance of Reflex
within 2 months.

53
 How to elicit/How to observe
Placing elicited by touching the anterior

Reflex surface of the lower part of a

newborn’s leg against a hard
surface such as the edge of a
bassinet or table

Normal Finding
The newborn
makes a few quick lifting
motions, as if to step onto the
table,

54
Plantar How to elicit/How Normal
Grasp Reflex to observe Finding
object touches the The toes grasp
sole of a newborn’s in the same
foot at the base of manner as do
the toes the fingers.

Disappearance of Reflex
This reflex disappears at 8–10
months.

55
Tonic Neck How to elicit/How to Normal Finding

Reflex observe
newborns lie on heads usually
their backs turn to one side
or the other

Disappearance of Reflex
This reflex disappears by 4–6 months.

56
Moro
How to elicit/How to Normal Finding
observe
hold newborns in a supine Sudden head
Reflex position and allow their
heads to drop backward
movement, they
abduct and extend
(STARTLE) about 1 inch their arms and legs.
they swing their
arms into an
embrace position
and pull up their
legs against their
abdomen

Disappearance of Reflex
This reflex disappears by 3 months.

57
Babinski How to elicit/How to
observe
Normal Finding

Reflex When the sole of the

foot is stroked in an
a newborn fans
the toes (positive
inverted “J” curve Babinski sign)
from the heel upward

Disappearance of Reflex
This reflex disappears within 2 years.

58
Magnet
Reflex
How to elicit/How Normal
to observe Finding
pressure is applied The baby
to the soles of the pushes back
feet of a newborn against the
lying in a supine pressure.
position

59
Trunk
Incurvation
Reflex (Galant) How to elicit/How to Normal Finding
observe
When newborns lie in a they flex their
prone position and are trunk and swing
touched along the their pelvis
paravertebral area by a toward the touch
probing finger

Disappearance of Reflex:
3-4 months

60
Landau
Reflex
How to elicit/How to Normal Finding
observe
A newborn who is held Should
in a prone position with demonstrate
a hand underneath, some muscle
supporting the trunk tone.

61
Deep Tendon How to elicit/How to Normal Finding

Reflex observe
elicited in a The lower leg
newborn by tapping the moves perceptibly
patellar tendon with if the infant has
the tip of the an
finger intact reflex

62
Inspect and palpate the head. Note shape
and symmetry. In newborns, inspect and palpate
the condition of fontanelles and sutures

63
64
NURSING PROCESS
OVERVIEW
Health Promotion of a Term Newborn

65
 ■ Assessment of a newborn or neonate (a
baby in the neonatal period) includes a
review of the mother’s pregnancy
history; physical examination of the
infant; analysis of laboratory indicated;
■ Parent–child interaction for the
beginning of bonding.
Assessment ■ Assessment begins immediately after
birth and is continued at every contact
during a newborn’s hospital or birthing
center stay, early home visits, and well-
baby visits.
■ Teaching parents to make assessments
concerning their infant’s temperature,
respiratory rate, and overall health is
crucial so that they can continue to
monitor their infant’s health at home
66
 ■ Ineffective airway clearance related
to mucus in airway
■ Ineffective thermoregulation
related to heat loss from exposure
Nursing in birthing room
■ Imbalanced nutrition, less than body
Diagnosis requirements, related to poor
sucking reflex
■ Readiness for enhanced family
coping related to birth of planned
infant
■ Health-seeking behaviors related to
newborn needs

67
 ■ Planning nursing care should take into
account both the newborn’s needs
during this transition period and a
mother’s need for adequate rest during
Outcome ■
the postpartal period.
Try to adapt teaching time to the
Identification and schedules of the mother and her
newborn.
Planning ■ Although the woman must learn as much
as possible about newborn care, she
also must go home from the health care
setting with enough energy to practice
what she has learned.
■ Important planning measures for
newborns include helping them regulate
their temperature and helping them
grow accustomed to breastfeeding or
bottle feeding.
68
 ■ A major portion of
implementation in the newborn
period is role modeling to help
new parents grow confident with
their newborn.
■ Be aware how closely parents
observe you for guidance in
Implementation newborn care.
■ Conserving newborn warmth and
energy, to help prevent
hypoglycemia and respiratory
distress, should be an important
consideration to accompany all
interventions.

69
 ■ Evaluation of expected outcomes should
reveal that parents are able to give
beginning newborn care with confidence.
■ Be certain parents make arrangements for
continued health supervision for their
newborn, so that evaluation can be

Outcome continued and the family’s long-term

health needs can be met.

Evaluation ■ Examples indicating achievement of

outcomes concerning newborns are:
• Infant establishes respirations of 30 to 60
per minute.
• Infant maintains temperature at 97.8°to
98.6°F (36.5° to 37° C).
• Infant bottle feeds or breastfeeds well with
a strong sucking reflex. ❧

70
71