EINC2 - SKILLS LAB

III. ANTHROPOMETRIC MEASUREMENTS

Vital statistics measured for a newborn usually consist of the baby’s weight, length, and
head and chest circumferences.
WEIGHT
• As long as newborns are breathing well, they are weighed nude and without a blanket.
• A newborn’s weight is important because it helps to determine maturity as well as
establish a baseline against which all other weights can be compared.
• According to CDC (2010) Growth Chart data, the average birth weight for a:
• mature female newborn is 3.4 kg (7.5 lb)
• male newborn is 3.5 kg (7.7 lb)
• The arbitrary lower limit of expected birth weight for all newborns is 2.5 kg (5.5 lb). Birth
weight exceeding 4.7 kg (10 lb) is unusual, but weights as high as 7.7 kg (17 lb) have
been documented (CDC, 2010).
• Place the newborn nude lying on a covered infant scale. Always keep a protective hand
over an infant on an infant scale (hovering but not touching) because infants squirm
readily and there is danger of them falling. Cover infant scales with scale paper before
weighing to prevent the spread of infection from one child to another.

LENGTH
• A newborn’s length at birth in relation to weight is a second important determinant used
to confirm that a newborn is healthy.
• The average birth length of a:
• mature female newborn is 49 cm (19.2 in.)
• mature male newborn is 50 cm (19.6 in.)
• The lower limit of expected birth length is arbitrarily set at 46 cm (18 in.). Although
rare, babies with lengths as great as 57.5 cm (24 in.) have been reported.

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 Length Measurement

ACTION RATIONALE
a. Place the newborn on a measuring Promotes accuracy
frame or examining table.
2. Align the newborn’s head snugly Provides a starting point for measuremen.t
against the top bar of the measuring
frame and ask an assistant to secure
the newborn.
3. Straighten the newborn’s body. Knees are difficult to straighten in newborns
because they usually keep them flexed.

4. Hold the newborn’s feet in a vertical Completes measurement.

position. Bring the foot board up
snuggle against the bottom of the foot.
5. If an examining table is used instead of Provides for an alternative approach
a measuring frame, mark the spots at
the top of the child’s head and bottom
of the feet on the table paper and then
measure between the marks with a
tape measure.
6. Plot height measurement on a Allows for interpretation of findings
standard graph

HEAD CIRCUMFERENCE
• is measured with a tape measure drawn across the center of the forehead and then
around the most prominent portion of the posterior head (the occiput).
• In a mature newborn, the head circumference is usually 34 to 35 cm (13.5 to 14 in.)
• A mature newborn with a head circumference greater than 37 cm (14.8 in.) or less than
33 cm (13.2 in.) should be carefully assessed for neurologic involvement, although
some well newborns have these measurements.
CHEST CIRCUMFERENCE
• Is measured at the level of the nipples. If a large amount of breast tissue or edema of
the breasts is present, this measurement will not be accurate until the edema has
subsided.
• The chest circumference in a term newborn is about 2 cm (0.75 to 1 in.) less than head
circumference.
ABDOMINAL CIRCUMFERENCE
• Is measured at the level of the umbilicus

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 IV. ASSESSING NEWBORN USING APGAR SCORING
I. DEFINITION
Apgar Scoring – is a tool for quick and accurate assessment of the condition of the
newborn at birth. It was devised by Dr. Virginia Apgar in 1952.

II. RATIONALE
1. The first – minute Apgar scoring is done to assess the well – being of the newborn
and to determine if there is a need for immediate resuscitation.
2. The five – minute Apgar scoring is done to:
• Assess the capacity of the newborn to adjust to the extra uterine environment.
• Evaluate the effectiveness of resuscitation measures, if done.
• Enable the nurse to formulate a plan of care for the newborn.

III. EQUIPMENT
Stethoscope Clean linen or layette
Nasogastric tube Fr 8 Apgar Score Chart

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IV. PLANNING AND IMPLEMENTATION

ACTION RATIONALE
1. Place the newborn in a crib or table To protect the newborn from
lined with a blanket or linen. contamination and injury.
2. Evaluate the heart rate. A significant index to cardiovascular
functioning.
- Observe the pulsation of the cord at
the abdomen if the cord is still uncut.
- Listen to the heart beat using a
stethoscope.
3. Observe for respiratory effort. Is the cry To determine if the newborn is responding
vigorous? well or has respiratory difficulty.
- Is there difficulty of breathing?
- Is there any presence of external
retraction or nasal flaring?
- Is the respiration “regular”?
4. Observe for muscular tonicity. To assess for muscular tonicity.
- Are the extremities well - flexed?
- Do they resist efforts to extend them?
- Are they flaccid and limp?
5. Evaluate the reflex irritability. To check for reflex irritability.
- How does the baby respond to gentle
slapping of the sole of the feet? To
suctioning?
- Is there no response at all?
- Is the cry weak or merely makes a
grimace?
6. Inspect the newborn’s entire body for To evaluate the cardiovascular
color. functioning. Color is an index to tissue
perfusion and Oxygenation of blood.

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V. ILLUSTRATION

1 5
ADAPTATION 0 1 2
min min
Less than
HEART RATE Absent Over 100 bpm
100 bpm
Slow,
RESPIRATORY Good, strong
Absent regular,
EFFORT cry
weak cry
Flaccid, Some flexion Well-flexed
MUSCLE TONE
Limp of extremities extremities
REFLEX No Weak cry,
Vigorous cry
IRRITABILITY response grimace
Body pink,
Completely
COLOR Blue, Pale extremities
pink
blue
TOTAL

VI. EVALUATION AND DOCUMENTATION

1. Evaluation of the newborn based on the five adaptation areas following any
sequence.
2. Score for each adaptation area.
3. Use of the Apgar Scoring chart for one minute and five minutes.
- A score of 7 to 10 indicates good condition with minimal special precaution to be
taken.
- A score of 4 to 6 means the baby is in fair condition and certain recommended
procedures are to be followed.
- A score of 0 to 3 means the newborn is in extremely poor condition and
resuscitation is needed immediately.