NEWBORN ASSESSMENT
usually is absorbed within 6 weeks with
Vital signs
Heart rate
- (resting): 120 to 160 beats/minute
- (sleeping) (80 to 100 beats/minute
- (if crying) Up to 180 beats/minute
Respirations
- 30 to 60 breaths/minute; assess for 1
full minute
Axillary temperature
- 96.8 °F (37 °C) to 99 °F (37.2 °C)
Blood pressure: Usually not done in term
newborn,
- 80–90/40–50 mm Hg
Body measurements (approximate)
1. Length: 18 to 22 inches (45 to 55 cm)
2. Weight: 2500 to 4000 g (5.5 to 8.75 lb)
3. Head circumference: 33 to 35 cm (13.2 to 14
inches)
Head
Sutures (connective tissue between the skull
bones)
Fontanels are unossified membranous tissue at
the junction of the sutures
A. the anterior fontanelle is located
between the two parietal bones and
the two frontal
bones which gives it a diamond shape, and
normally closes at 12 to 18 months of age.
B. The posterior fontanelle is located at
the junction of the parietal bones and
the occipital
Bone and is triangular in shape and close at the
end of the second month.
Molding is asymmetry of the head resulting
from pressure in the birth canal; molding
disappears in about 72 hours
Masses from birth trauma
a. Caput succedaneum is edema of the soft
tissue over bone (crosses over suture line); it
subsides within a few days.
b. Cephalhematoma is swelling caused by
bleeding into an area between the bone and its
periosteum (does not cross over suture line); it
no treatment
Head lag
1. Common when pulling the newborn to a
sitting position
2. When prone, the newborn should be able to
lift the head slightly and turn the head from side
to side.
Eyes
1. Slate gray (light skin), dark blue, or brown-
gray (dark skin)
2. Symmetrical and clear
3. Pupils equal, round, react to light and
accommodation
4. Blink reflex present
5. Eyes cross because of weak extraocular
muscles
6. Ability to track and fixate momentarily
7. Red reflex present
8. Eyelids often edematous as a result of
pressure during the birth process and the
effects of eye medication
Ears
1. Symmetrical
2. Firm cartilage with recoil
3. Top of pinna on or above line drawn from
outer canthus of eye
4. The newborn’s external ear is not yet fully
formed, and the top part of the external ear
should be on a line drawn from the inner
canthus to the outer canthus of the eye and
back
across the side of the head.
5. Low-set ears associated with Down
syndrome, renal anomalies, or other genetic or
chromosomal syndromes
Nose
1. Flat, broad, in center of face
2. Obligatory nose breathing
3. Occasional sneezing to remove obstructions
4. Nares are patent and should not flare (flaring
is an indication of respiratory distress).
5. The newborn’s nose tends to look large for
the face but the rest of the face will grow more
than the nose does.
Mouth
1. Pink, moist gums
2. Soft and hard palates intact
3. Epstein’s pearls (small, white cysts) may be
present on hard palate.
4. Uvula in midline
5. Freely moving tongue, symmetrical, has short
frenulum
6. Sucking and crying movements symmetrical
7. Able to swallow
8. Root and gag reflexes present
9. The newborn’s mouth must open evenly
when he or she cries.
Neck
1. Short and thick
2. Head held in midline
3. Trachea midline
4. Good range of motion and ability to flex and
extend
5. Assess for torticollis (head inclined to 1 side
as a result of contraction of muscles on that
side
of the neck)
Chest
1. Circular appearance because anteroposterior
and lateral diameters are about equal
(approximately 30 to 33 cm [12 to 13.2 inches]
at birth)
2. Diaphragmatic respirations—chest and
abdomen should rise and fall in synchrony, not
in seesaw pattern
3. Bronchial sounds heard on auscultation
4. Nipples prominent and often edematous;
milky secretion (witch’s milk) common
5. Breast tissue present
6. Clavicles need to be palpated to assess for
fractures.
Skin
Vernix caseosa, a cheesy white substance
Lanugo, fine body hair
Milia, small white sebaceous glands, appear on
the forehead, nose, and chin
Acrocyanosis (peripheral cyanosis of hands and
feet)
Harlequin sign or when a newborn who is lying
on his or her side appears red on the dependent
side and pale on the upper side does not have a
clinical significance
Hemangiomas are vascular tumors of the skin
Nevus flammeus are muscular purple or dark
red lesion. Generally, appear on the face and
thighs
Strawberry hemangiomas—elevated areas
formed by immature capillaries and endothelial
cells
Cavernous hemangiomas—these are dilated
vascular spaces.
Mongolian spots—slate gray patches across the
sacrum or buttocks and consist of a collection of
pigment cells.
Forceps marks—these are circular or linear
contusion matching the rim of the blade forceps
on the infant’s cheeks.
Abdomen
Umbilical cord
- Umbilical cord should have 3 vessels—2
arteries and 1 vein
- Cord should be clamped for at least the
first 24 hours after birth; clamp can be
removed when the cord is dried and
occluded and is no longer bleeding.
Genitals
1. Female
a. Labia may be swollen; clitoris may be
enlarged.
b. Smegma may be present (thick, white
mucus discharge).
c. Pseudo- menstruation, caused by the
withdrawal of the maternal hormone
estrogen, is possible (blood-tinged mucus).
d. Hymen tag may be visible.
d. First voiding should occur within 24
hours.
2. Male
a) Prepuce (foreskin) covers glans penis.
b) Scrotum may be edematous.
c) Verify meatus at tip of penis.
d) Testes are descended but may retract
with cold.
e) Assess for hernia or hydrocele.
f) First voiding should occur within 24
hours.
Palmar Grasp Reflex - Objects placed on
newborns’ palms will be grasped by
newborns.
Walk-in-Place Reflex - If newborns are held
in a vertical position with their feet
touching a hard-solid surface, newborns will
take few, alternating steps.

BLOOD Tonic Neck Reflex - is also called boxer of

Blood volume of a new born depends upon
placental transfer of blood. The blood
volume of a full-term infant is about 80-
85ml/kg of body weight
✓ Immediately after birth the total blood
volume averages 300ml but depending on
how long umbilical cord clamping is delayed
or the umbilical cord is milked, as much as
100 ml can be added.
A pale and cyanotic newborn signifies that
she may have poor central nervous system
control.
fencing reflex
Moro Reflex - “drop method” wherein the
nurse lifts the baby completely off the bed
while supporting the head and the neck,
and then the nurse lowers the baby rapidly
till there is only 4-8 inches between the
baby and the bed.
Babinski Reflex - When the nurse strokes
the sole of the foot in an inverted “J” curve
from the heel upward, the newborn’s toes
fan.

• A gray color in newborns may indicate

infection

Central cyanosis, however, is a cause for

concern as this may indicate a decrease in
oxygenation.

Jaundice appears on the second or third

day of life as a result of the breakdown of
fetal red blood cells.

• Early feeding to speed the passage of

feces through the intestine and prevent
reabsorption of bilirubin from the bowel
may diminish physiologic jaundice.

• Pallor in newborns is a sign of anemia,

and the newborn must be watched closely
for signs of blood in the stool or vomitus.

11 newborn reflexes:

Rooting Reflex - Brushing the cheek or

stroking near the mouth of the newborn
will cause the head of the newborn to turn
to that direction.

Blink Reflex - It can be elicited by shining a

strong light (e.g. flashlight, otoscope light,
etc.) on the eyes.

Sucking Reflex - Touching the newborn’s

lips causes the baby to make sucking
motions.

Extrusion Reflex - Until four months of age,

any food placed on the anterior portion of
the tongue of babies will be expelled by
them.