NORMAL NEONATE AND

GENERAL EXAM OF THE

NEWBORN

BY
RUQAYYA HAMZA
Nursing assessment of the normal newborn

 Assessment criteria
– The initial assessment using the Apgar scoring
system.
– Transitional assessment (periods of reactivity).
• The examination should be conducted in a warm
area that is free from dampness to protect the
newborn from chilling.
• There should be plenty of light available to facilitate
visual inspection. Indirect lighting works best.
• All equipment should be checked for proper
functioning and should be readily available to allow
for economy of motion.
• An experienced practitioner can complete a
thorough examination in a short period of time,
which is ideal because newborns become easily
fatigued when overstimulated by prolonged
examination.
• Order of progression is from general
observations to specific measurements.
• Complete least disturbing aspects of the
examination before more intrusive techniques
are used.
• Proceed using a head-to-toe approach.
• Evaluate overall physical appearance of the
newborn followed by measurement of vital
signs, weight, and length.
• Then a thorough head-to-toe assessment is
done, ending with assessment of neurologic
reflexes and the gestational age assessment.
• The behavioral assessment is integrated
throughout the examination as the
practitioner notes how the newborn responds
to sensory stimulation.
First period of reactivity: (6-8 hours after birth)
Initial stage: first 30mins
• Newborn is very alert, cries vigorously, may
suck his fist and appears very interested in his
environment, eyes are usually open, vigorous
suck reflex.
• The respiratory rate can be high as 80
breaths/minute, crackles may be heard, heart
rate may reach 180 beats/minute, bowel
sounds are active, mucous secretions are
increased and temperature may decrease.
Second stage: It lasts 2-4 hour.
– Heart and respiratory rates decrease
– temperature continues to fall
– mucous production decreases
– urine or stool is usually not passed.
– The infant is in a state of sleep and relatively
calm
 APGAR SCORING SYSTEM

- A score of 7-10 indicates a healthy newborn,

- A score of 4-6 is considered moderately
depressed.
- A score of 0-3 is severely depressed
Assessment of gestational age
• Gestational age should be assessed within the
first 4 hours of birth for maximum reliability. The
New Ballard Score is often used which takes
into account both neuromuscular and physical
maturity. The score sheet include scales that
have grades of -1 through 5.

• The total score is then correlated with the

corresponding number of weeks to give the
clinical determinant of the newborn's age.
• It is best performed at <12 hrs of age if the
infant is <26 weeks' gestation. If the infant is
>26 weeks' gestation, there is no optimal age
of examination up to 96 hrs.
Maturational Assessment of Gestational Age.
► Name - Date/time of birth - Sex - Race
► Date/time of examination - Postnatal age (in
hours) when examined
► Birth weight - Length - Head circumference
► Apgar score: at 1, 5, and 10 minutes
• Physical maturity is most accurately assessed
immediately after birth.
• If the infant was compromised during labor
and delivery, neurological maturity may not be
accurately assessed at this time and should
therefore be repeated after 24 hrs of age.
• If the neurological assessment is not
performed, the GA estimate can be based
upon a doubling of the physical assessment
score.
Neuromuscular maturity
• Posture
 The infant is placed supine and the examiner
waits until the infant settles into a relaxed or
preferred posture.
 Observe the flexion of the arms and legs.
 Compare with the figures on the diagram and
place an (X) through the figure most similar.
• Square window
 Flex the infant's hand at the wrist and
observe the angle between the thumb and
forearm. Apply gentle pressure to get as
much flexion as possible.
 Compare the angle at the thumb with the
figures on the diagram and choose the figure
most similar.
• Arm recoil
 Place the infant in the supine position.
 Flex the forearms for 5 seconds; then grasp the
hand and fully extend the arm and release.
Observe the infant’s arm reaction to the
release.
► Score (0): Infant' arm remains extended
► Score (1): Partial flexion to 140-180º
► Score (2): Flexion to 110-140º
► Score (3): Flexion to 90-100º
► Score (4): Brisk return to full flexion
• Popliteal angle
 With infant lying supine, and with diaper
removed and pelvis flat on the examining
surface.
 Hold the thigh in the knee-chest position with
the left index finger and the thumb supporting
the knee. Then extend the leg by gentle
pressure from the right index finger behind the
ankle.
 Compare the angle behind the knee or the
popliteal angle, with the figures on the diagram.
• Scarf sign
 Place the infant in the supine position.
 Hold the infant's hand and draw the arm as far across
the neck (like a scarf) to the opposite shoulder as
possible.
 To perform this maneuver the elbow may need to be
lifted across the body, but both shoulders should
remain on the examining surface and the head should
remain midline.
 The point on the chest to which the elbow moves
easily prior to significant resistance is noted.
 Observe the position of the elbow on the infant's
chest and compare it to the figures on the diagram.
• Heel-to-ear-maneuver
• The infant is placed supine and the flexed lower extremity is
brought to rest on the mattress alongside the infant's trunk.
• Support the infant's thigh laterally alongside the body with
the palm of one hand. Hold the infant's foot between the
thumb and index finger of the other hand and draw it to as
near the head as possible towards the ipsilateral ear
without forcing it. Keep the pelvis flat on the examining
surface.
• Note the location of the heel where significant resistance is
appreciated.
• Observe the distance between the foot and the head and
the degree of extension at the knee and compare this to the
figures on the diagram.
 General Body Proportions and Posture
• Head is large in proportion to the rest of the
body.
• The newborn’s neck is short, and the chin rests
on the chest.
• The newborn maintains a flexed position with
tightly clenched fists.
• The newborn’s abdomen is protuberant and his
chest is rounded. Note the newborn’s sloping
shoulders and rounded hips.
• The newborn’s body appears long with short
extremities.
Systematic physical examination 

General Measurement
• Birth weight: 2700-4000 gm.
• Head Circumference: 33-35.5 cm.
• Chest Circumference: 30.5-33 cm.
• Length: 48-53 cm.
General Appearance
Posture: Complete flexion as a result of utero
position.
Skin
• Assess Skin turgor to determine hydration
status, the need to initiate early feedings, and
the presence of any infectious processes.
• The areas used to assess skin turgor is over
the abdomen, forearm, or thigh.
• Skin should be elastic and should return
rapidly to its original shape.
• Nevus vasculosus (strawberry mark) is a
capillary hemangioma. It consists of newly
formed and enlarged capillaries in the dermal
and subdermal layers. It is a raised, clearly
delineated, dark red, rough-surfaced birthmark
commonly found in the head region.
• Such marks usually begin to grow (often rapidly)
during the second or third week of life and may
not reach their full size until about 6 months of
age
Skin:
• Bright red, smooth and puffy
especially eyes, legs, the
dorsal aspect of the hand,
feet and the scrotum or labia.
In observing the skin, we find:
a- Vernix caseosa: white cheesy
substance and it is present on
the back, head, body creases
and between labia. It wears
off with in 24-48 hours.
Lanugo hair: long soft
growth of fine hair
observed on the
shoulder, back,
extremities, forehead
and temples of the
neonate. the hair will
fall off within the first
few weeks of life.
• Mongolian spot:
dark discolored area
found over the
lower back and
sacrum. This
disappear during
preschool years
• Milia: white pinpoint
spots on a newborn
that resemble
whiteheads. Called
"Baby Acne" on the
nose & chin.
Disappear with in
afew weeks. They
should not be
expressed.
• Desquamation:
Pealing of the skin
occurs within 2-4
weeks of life. These
are denoted area
where delicate skin
has been rubbed off
the nose, knees and
elbow because of
pressure and erosion
of sheets.
Salmon patch: a very common group of
birthmarks seen in babies caused by
expansions (dilations) in tiny blood vessels
called capillaries. It is often called an angel kiss
when it occurs on the face and stork bite
when it occurs on the back of the neck.
• Angel kisses tend to fade by age 1–2 and stork
bites do not go away at all but are usually
covered by the hair on the back of the head.
• Head: Contain two fontanels (the anterior
fontanel and posterior fontanel).
• The anterior fontanelle (diamond in shape) is 3
to 4 cm long by 2 to 3 cm wide. It is located at
the juncture of the frontal and parietal bones.
• The posterior fontanelle (triangular in shape)
is smaller and is formed by the parietal bones
and the occipital bone and is 0.5 cm by 1 cm
• The anterior fontanelle closes within 18 months,
whereas the posterior fontanelle closes within 8
to 8 weeks.
• The fontanelles are a useful indicator of the
newborn’s condition.
• The anterior fontanel may swell when the
newborn cries or passes a stool or may pulsate
with the heartbeat, which is normal.
• A bulging fontanelle usually signifies increased
intracranial pressure, and a depressed fontanelle
indicates dehydration.
There is two condition may appear in the head.
1- Caput Succedaneum: a localizing, pitting
oedema in the scalp resulting from pressure
during labour. No specific treatment is needed,
and the swelling subsides within a few days.
• 2- Cephalohematoma: it is a hemorrhage
under the periosteum of one of the cranial
bones resulting from trauma during labour.
• The head may be misshapen because of
molding, an elongated shape caused by
overlapping of the cranial.
• Any extreme difference in head size may
indicate microcephaly or hydrocephalus (an
abnormal buildup of fluid in the brain).
• Variations in the shape, size or appearance of
the head may be due to craniosynostosis
(premature closure of the cranial sutures), or
plagiocephaly (asymmetry resulting in closure
of sutures on one side caused by pressure on
the fetal head during gestation).
Face: The newborn’s face is well designed to help the
newborn suckle.
• Facial movement symmetry should be assessed to
determine the presence of facial palsy.
• Facial paralysis appears when the newborn cries; the
affected side is immobile, and the palpebral (eyelid)
fissure widens.
• Facial paralysis usually disappears within a few days to
3 weeks, although in some cases it may be permanent.
Eyes:
• The eyes should be checked for size, equality of
pupil size, reaction of pupils to light, blink reflex to
light, and edema and inflammation of the eyelids.
• It is normal for the eyelids to be swollen from
pressure during birth. A chemical conjunctivitis may
develop after instillation of eye prophylaxis in the
delivery room.
• The sclera should be clear and white, not blue. The
pupils should be equal and reactive to light. Small
subconjunctival hemorrhages may be present. These
usually disappear within a week or two and are not
harmful.
• Eye movements are usually uncoordinated,
and some strabismus (crossed eyes) is
expected. A “doll’s eye” reflex is normal for
the first few days: that is, when the newborn’s
head is turned, the eyes travel to the opposite
side.
• Crying is usually tearless because the lacrimal
apparatus is underdeveloped.
• The nurse should observe the newborn’s
pupils for opacities or whiteness and for the
absence of a normal red retinal reflex.
• Red retinal reflex is a red-orange flash of color
observed when an ophthalmoscope light reflects
off the retina.
• Brushfield spots (black or white spots on the
periphery of the iris) can be associated with
Down syndrome.
• Poor oculomotor coordination and absence of
accommodation limit visual abilities, but
newborns do have peripheral vision and can
fixate on near objects.
• Nose: assess for placement, shape, patency, and
the presence of drainage. The nose should be
midline on the face. Nares should be symmetrical
in placement and size.
• Newborn’s nose is flat, and the bridge may
appear to be absent. The nostrils should be
bilaterally patent because the newborn is an
obligate nose breather.
• Newborn clears obstructions from the nose by
sneezing. There should be no nasal flaring, which
is a sign of respiratory distress. The sense of smell
is present, as evidenced by the newborn’s turning
toward milk and by turning away from or blinking
in the presence of strong odours.
Mouth: symmetry, completeness, size, and color
are considerations. The mouth should be
midline and symmetrical. Asymmetrical
movement may be caused by nerve injury
from birth trauma and may include other
parts of the face.
• Inspect the mouth, lips, tongue, and gums for
deformities. Epstein's pearls, small calcium
deposits that form midline on the hard palate,
may be present. They will reabsorb within
approximately one week.
• The mucous membranes should be moist and
pink.
• The suck reflex should be strong, the gag
reflex present, and both the hard and soft
palates should be intact. Well-developed fat
pads are present bilaterally on the cheeks.
• Precocious teeth may be present on the lower
central portion of the gum. The teeth will
need to be removed if they are loose to
prevent the infant from aspirating them.
• Ear: should include size, shape, and location.
Ear cartilage becomes firmer as the fetus ages.
• The pinna should be flexible with quick recoil,
indicating the presence of cartilage. The top of
the pinna should be even with, or above, an
imaginary horizontal line drawn from the inner
to the outer canthus of the eye and continuing
past the ear.
• Low-set ears are associated with congenital
defects, including those that cause mental
retardation and internal organ defects.
Neck:
• noticeably shorter and more flexible than that
of an adult or child. The normal newborn will
exhibit creasing and skin folds on the neck.
• Significant head lag is present when the
newborn is pulled to a sitting position from a
supine one. Newborns can hold up their heads
slightly when placed on their abdomens.
There should be no masses or webbing.
• The clavicles should be intact. If fractured, a lump
and a grating sensation (crepitus) during
movements may be palpated along the course of
the side of the break.
• An asymmetrical Moro reflex is another indication
• The neck is palpated for masses and presence of
lymph nodes and is inspected for webbing.
• Injury to the sternocleidomastoid muscle
(congenital torticollis) must be considered in the
presence of neck rigidity.
Chest: the anteroposterior and lateral diameters
of the chest are equal, making the chest
appear barrel-shaped.
• The xiphoid process is prominent. Chest
movements should be equal bilaterally and
synchronous with the abdomen.
• Breast enlargement and engorgement is
normal for both sexes. A thin milky secretion,
sometimes called “witch’s milk,” may be
secreted from the nipples. The breasts should
not be squeezed in an attempt to express the
liquid. Assess for supernumerary (accessory)
nipples below and medial to the true nipples.
Abdomen:is dome shaped and protuberant.
Respirations are typically diaphragmatic.
Peristaltic waves should not be visible.
• Bowel sounds should be audible within 2
hours of birth. The abdomen should be soft to
palpation without palpable masses. The
umbilical cord should be well formed, with
three vessels present. The base of the cord
should be dry without redness or drainage,
and the umbilical clamp should be fastened
securely.
• A scaphoid (hollow-shaped) appearance suggests
the absence of abdominal contents, as seen in
diaphragmatic hernia. There should be no gross
distention or bulging.

• Distention is the first sign of many of the

gastrointestinal abnormalities. Before palpation
of the abdomen, the nurse should auscultate the
presence or absence of bowel sounds in all four
quadrants. Bowel sounds should be present by 1
hour after birth.
 Systems Assessment

Gastrointestinal system:
• Mouth: should be examined for abnormalities
such as cleft lip, cleft palate and oral candidiasis.
• Gum: may appear with irregular edges
sometimes back of the gum may be whitish,
deciduous teeth are semi formed but not
erupted.
• Cheeks: have a chubby appearance due to
development of fatty sucking pads.
• Stomach and intestine: the capacity of child's
stomach varies after birth from 30-60 cc and
increase rapidly.
Circulatory system: 
• heart: heart sounds include the first (S1) and the
second (S2) should be clear and well defined.
• Auscultation of heart sounds
• The aortic area, which is defined as the second
intercostal space at the right of the sternum.
• The pulmonic area, which is located at the second
intercostal space to the left of the sternum.
• Erb's point, which is located at the third intercostal
space to the left of the sternum.
• the tricuspid area, which is located in the fifth
intercostal space to both the left and right of
the sternum.
• The apical/mitral area, which is found at the
fourth intercostal space at the left of the
midclavicular line.
The respiratory system
– Slight sternal retraction evident during inspiration.
– Xiphoid process evident.
– Respiratory chiefly abdominal.
– Cough reflex absent at birth, present by 1-2 days.
Genitourinary system:
• Newborn has urine in the bladder and voids at
birth or some hours later. The newborn should void
within the first 24 hours of life. The kidneys are not
able to concentrate urine well during the first few
days, so the colour is light, and there is no odour.
• It is normal to find a small amount of pink or light
orange colour in the diaper for the first few
voidings.
• Both male and female
genitalia may be
swollen. Smegma, a
cheesy white
sebaceous gland
secretion, is often
found within the folds
of the labia of the
female and under the
foreskin of the male.
Female genitalia:
• Labia and clitoris usually edematous.
• Urethral meatus behind clitoris.
• Vernix caseosa between labia, the labia majora
cover the labia minora.
• A hymenal tag may be present.
• A blood-tinged mucous secretion may be
discharged from the vagina in response to the
sudden withdrawal of maternal hormones
(pseudomenstruation).
Male genitalia:
• urethral opening is at top of glans pens.
• Tests palpable in each scrotum.
• Scrotum usually large edematous and covered
with rugae.
• The scrotum should be inspected for size and
symmetry.
• The scrotum should be palpated to verify the
presence of both testes and to rule out
cryptorchidism (failure of testes to descend).
• Hypospadias occurs when the urinary meatus is
located on the ventral surface of the penis;
epispadias occurs when the meatus is located on
the dorsal surface of the glans.
• Phimosis is a condition occurring in newborn
males in which the opening of the foreskin
(prepuce) is small, and the foreskin cannot be
pulled back over the glans at all.
• The testes are palpated separately between the
thumb and forefinger, with the thumb and
forefinger of the other hand placed together over
the inguinal canal.
• Scrotal edema and discoloration are common in
breech births.
• Hydrocele (a collection of fluid surrounding the
testes in the scrotum) is common in newborns
and should be identified. It usually resolves
without intervention.
The anus:
• The anal area is inspected to verify that it is
patent and has no fissure.
• Imperforate anus and rectal atresia may be ruled
out by observation.
• The passage of the first meconium stool is also
noted.
• In the absence of meconium passage in the 1st 24
hrs of life, Atresia of the gastrointestinal tract or
meconium ileus with resultant obstruction is
considered
Endocrine system: after birth there is withdrawal of
maternal hormones and cause some normal phenomena
such as:
• Swollen breasts: this appears on the 3rd day in both
males and females. It lasts for 2-3 weeks and gradually
disappears without treatment.
• Pseudo menstruation: this is consisting of few spots of
blood for 1-2 days can be seen in the diaper. 
The nervous system:
• Immatured, as the infant grows and develops, a more
certain presentation of the intactness of the neurological
system will surface. When assessing neurological status,
one should be alert for warning signs and then proceed
by assessing the newborn's reflexes.
Reflexes:
• Protective reflexes as: blinking reflex,
coughing and sneezing reflex, and gagging
reflex.
• Feeding reflexes as: rooting reflex, sucking
reflex, and swallowing reflex.
• Other reflexes as: grasp reflex, moro reflex,
tonic neck reflex.
 
MORO REFLEX:
• Symmetrical and present for the 1st 8 weeks of
life. It occurs in response to a sudden stimuli.
• This is elicited by holding the baby at an angle of
450/supine position, support the head and trunk
from below and then permitting the head to drop
1 or2cm.
• The infant respond by abduction and extension
of arms with fingers fanned and sometimes
accompanied by tremor
 
• The arms then flex and embrace the chest, same
with the legs which follows extension, flex onto
the abdomen.
• It is often accompanied by a cry
• Fracture of the humerus or clavicle or brachial
palsy causes an asymmetric moro response
• Absence may indicate brain damage or
immaturity. Persistent after six months is
suggestive of mental retardation/ learning
difficulties.
• ROOTING REFLEX: the baby will turn towards
the source of the stimulus and open the mouth
ready to suckle when stroking the cheek or side
of the mouth.
• SUCKING AND SWALLOWING REFLEX: are well
developed in a normal baby and are coordinated
with breathing. They are essential for safe
feeding and adequate nutrition.
• COUGHING AND SNEEZING REFLEX: are used to
protect the child from airway obstruction.
• BLINKING AND CORNEAL REFLEX: is used to
protect the eye from trauma.
• GRASP REFLEX: a palmar grasp is initiated by
placing a finger or pencil on the palm of the
baby’s hand, the finger or pencil is grasped
firmly.
• Plantar grasp is similar to palmar grasp by
stroking the base of the foot.
• WALKING AND STEPPING REFLEX: the child
stimulates walking when supported upright with
feet touching a flat surface
• LIMB PLACEMENT REFLEX: when the baby is held
with the tibia in contact with the edge of the
table, the baby will step up onto the table
• ASSYMETRICAL TONIC NECK REFLEX: when the
baby is held in supine position, the limbs on the
side of the body to which the head is turned to
extend while those on the opposite side flex.
• TRACTION RESPONSE: when the baby is pulled
upright by the wrist in sitting position, the head
will lag, then right itself momentarily before
falling forward onto the chest.

• VENTRAL SUSPENSION: when the child is held in

prone position on the examiner’s arms, the baby
momentarily holds his head at the level with his
body and flexes the limbs.
traction
Ventral suspension
 Disappears
Reflex Appears Brief Description
(Approximate)

Turns mouth to the same side of the

Generally becomes
cheek that is being stroked
Rooting At birth voluntary after 3 weeks
of age

Strong coughs in response to

Continues into stimulation of the posterior oral
Gag At birth
adulthood cavity

When dropped slightly, quickly

At birth- abducts extremities and forms the

Moro index finger and thumb into a "c"
8wks 6 months of age
(startle) shape
 When the infant's head in turned to
Between
Tonic one side, with the jaw over the
birth and
neck 4 to 6 months of age shoulder, the arm and the leg on the
2 months
(fencing) infant's same side extend while the
of age
opposite arm leg flex
Wraps fingers around the examiner's
Palmar finger when it is placed into the
At birth 4 to 6 months of age
grasp infant's palm

Curls toes downward in response to

Plantar pressure applied to the sole of the
At birth 8 months of age
grasp foot at the base of the toes

Flex the big toe when an object is

Babinski' dragged along the sole of the foot
At birth 2 years of age
s from the heel to the head of the 5th
metatarsal
Hips:
• Done to detect developmental dysplasia of the
hips
• Place the child on a firm flat surface at waist
region
• Ortolani’s test: grasp the baby’s legs with the
knees flexed in the palms of the examiner’s hands
and the femur splinted between the index and
middle fingers and the thumbs. Examine both
hips simultaneously. The baby’s thigh are flexed
on to the abdomen and rotated and abducted
through an angle of 70-90o towards the examining
surface
• Force should not be exerted. If the hip is
dislocated, a “clunk” will be felt as the head of
the femur slips into the acetabulum during
adduction and the dislocation is reduced
• BARLOW’S TEST: with the baby’s legs flexed, the
head of the femur is held in between the
examiners thumb and index finger while the other
hand steadies the pelvis. Abduct hip to 70o, gentle
pressure is exerted in a backward and lateral
direction. “A clunk” will be felt as the head of the
femur dislocates out of the acetabulum
The organization and quality of the newborn
motor activity are influenced by a number of
factors such as :
• Sleep alert states
• Presence of environmental stimuli such as
heat, light, cold and noise
• Conditions causing chemical imbalance e.g.
hypoglycaemia
• Hydration status
• State of health
• Recovery from the stress of labour and birth
Extremities
-Ten fingers and toes.
- Full range of motion.
- Symmetry of extremities.
- Nail beds pink with transient cyanosis.
• Fusing or webbing of the toes or fingers
(Syndactyly) and extra digits (polydactyly )are
present . The palms of the hands should have
creases. A single straight palmar crease, a
simian crease, is abnormal finding associated
with Down syndrome.
• Brachial pulses should be present and equal.
• The legs are bowed and the feet flat because of a
fatty pad in the arch of the foot. Creases should
cover atleast two thirds of the bottom of the feet.
• Palpate the femoral and brachial pulses on each
side of the body. The pulses should be equal and
strong.
• Elicit Ortolani’s maneuver and Barlow’s sign to
evaluate the hip for signs of dislocation or
subluxation (partial dislocation).
• Back and Rectum The spine is straight and flat.
The lumbar and sacral curves do not appear until
the infant begins to use his back to sit and stand
upright. Feel along the length of the spine.
• There should be no masses, openings, dimples, or
tufts of hair. Any of these findings may be
associated with spina bifida (an opening in the
spinal column with or without herniation of the
meninges).
SPINE:
• With the baby lying in prone position, the
midwife should inspect and palpate the baby’s
back. Any swelling, dimples or hairy patches may
signify an occult spinal defect.
• The spine should appear straight and flat because
the lumbar and sacral curves do not develop until
the infant begins to sit.
• The base of the spine is examined for a dermal
sinus. The nevus pilosus (“hairy nevus”) is
occasionally found at the base of the spine in
newborns.
• A pilonidal dimple should be examined to
ascertain that there is no connection to the
spinal canal