Newborn Assessment

Posture - full term neonate posture is one of complete flexion as a result of in utero position.

Behavior - watch degrees of alertness, drowsiness, irritability (sx of nerological problems), look for symmetry of movement

Skin - texture of skin is velvety smooth & puffy, especially around eyes, legs, dorsal aspect of hands/feet, & the scrotum or labia. Color depends on race: Caucasian - pink/red, Black - pinkish or yellowish brown, Hispanic - olive or yellow tint, Asian - rosy or yellowish tan, Native American - light pink to dark reddish brown depending on tribe. Color normalizes to more natural tone in 2-3 days; Mongolian Spots - looks like bruises in sacral & gluteal areas, common in Asian/Black babies. Vernix Caseosa cheesy white protection against drying effects of amniotic fluid, insulator; Lanugo fine hair appears at about 20 weeks disappears as baby ages. Milia distended sebaceous glands around mouth & nose. Erythema Toxicum newborn rash can be anywhere. Port Wine Stain birthmark, large permanent, removed by laser.

Head - 33-37cm in circumference; Contour - molding occurs in almost all vaginal births, more oval contour apparent in 1-2 days; 6 bones frontal, occipital, 2 parietal, 2 temporal, bones may overlap causing ridges at first d/t pressure of birth; Caput succendaneum edema of soft scalp tissue d/t prolonged pressure, apparent at birth, bruises, crosses suture lines; Cephalhematoma hematoma between periosteum & skull bone, does not cross suture lines, does not bruise, not apparent at birth;  Fontanels anterior (at sagittal, coronal, & frontal sutures) is diamond shaped; posterior is found by following sagittal suture toward occiput. Fontanels should feel flat, firm, & well defined against bony edges of skull. Pulsations may be visible. Head Control - head lag is normal, excessive head lag may indicate Down syndrome, prematurity, hypoxia, or brain damage. When in a sitting position the infant will attempt to control head. When held in ventral suspension the infant will hold the head in line w/spinal column.

Eyes - edema is normal for first 2 days. Check symmetry. Tears may be present but purulent drainage is abnormal. Hold infant supine & gently lower head, eyes will open much like a doll. Sclera should be white/clear. Pupils will usually respond to light w/constriction, pupils are often malaligned. Searching nystagmus is common. Strabismus is common d/t lack of muscle control

Ears - position, structure, & function: Pinna should be in line w/outer canthus of eye. Low set ears may indicate renal abnormalities, Down syndrome, Fetal Alcohol Syndrome, etc... Startle Reflex observed when there is a sudden loud noise near infant or the bassinet is bumped into suddenly, this depends on the infants state at the time.

Nose - bruises are common, check patency of canals by holding mouth closed & closing 1 canal at a time. Infants are obligatory nose breathers Sneezing & thin mucus are common. Nasal flaring indicates distress.

Mouth/Throat - check for cleft lip/cleft palate, Epstein pearls are common epithelial cysts. A tight lingual frenulum may limit sucking ability (tongue tied). Sucking Reflex place a nipple or gloved finger in the infants mouth & the infant should vigorously suck. Rooting Reflex stroke the cheek & the infant should turn toward the stimulated side. Teeth are often found if there are developmental abnormalities.

Neck - short, many folds, hyperextend the head to examine. Check ROM, shape, look for masses, & palpate & compare clavicles for fractures. Tonic Neck Reflex infant’s head turned to 1 side, arm & leg extend on that side, & opposite arm & leg flex.

Chest - 31-35cm in circumference; shape is almost circular, ribs are flexible. Check breasts for size, shape, nipple formation & number. Breasts often enlarged.  “Witch’s Milk” happens occasionally by the end of the 1^st week. Supernumerary nipples may be on chest or in axilla.

Lungs - resps 30-60/min, irregular & abdominal, pauses of up to 20 seconds are normal. Crackles immediately after birth are normal. Wheezes, coarse crackles or stridor are abnormal.

Heart - location can be roughly indicated by the Point of Maximum Intensity (4^th or 5^th intercostal space).  Dextrocardia an anomaly where the heart is on the right side of the body. Murmur is common in newborns.

 Rate should be 100-180 soon after birth, more stabilized at 120-140/min.

Abdomen - Contour cylindric & usually protruding d/t weak muscles & large organs, w/a few visible veins. Bowel Sounds are usually heard 15-20 minutes after birth. Umbilical Cord should have 2 arteries & 1 vein (larger than arteries w/thinner vessel wall). Assess stump for sx of infection.  Palpate for femoral pulses which should be strong & equal.

Female Genitalia - labia minora, labia majora, & clitoris are normally edematous. Identify evidence of ambiguous genitalia. Vaginal discharge may be noted during first week (pseudomenstruation d/t abrupt decrease of maternal hormones). Vernix caseosa may be present between labia. First urine should be within 24 hours.

Male Genitalia - inspect penis for location of urethral opening. Hypospadias urethral opening on ventral surface of penis. Epispadias urethral opening on dorsal surface of penis. Tight foreskin is common & should not be forcefully retracted. Scrotum may be large, edematous, & pendulous, also more deeply pigmented in dark skinned babies. Hydrocele (fluid in scrotum) commonly occurs unilaterally & disappears w/in a few months. Check for the presence of both testes, undescended testes (Cryptochidism)  may be palpable w/in the inguinal canal. An inguinal hernia may or may not be manifested immediately after birth. Phimosis when foreskin has been retracted & can’t be pulled back up over glans penis. Circumcisions are done on day 2, unless Jewish, then day 8. Either Gomco or Plastibell (or Mogen if Jewish). Cremaster Reflex stroke near inner thigh/groin & same side scrotum rises. First urine should be w/in 24 hours.

Back & Anus - inspect spine w/infant prone, should be gently rounded. A protruding sac anywhere along spine (most common in sacral area) indicates some type of Spina Bifida. The passage of meconium during the first 24-48 hours indicates anal patency. Anal Reflex stroke skin next to anus. Make sure dimple between buttocks is fully closed. Trunk Incurvation Reflex rub back along side of spine & same side hip pulls up.

Extremities - Symmetry, count the digits & look for syndactyly, nail beds should be pink (may be blue in acrocyanosis, which is normal for the 1^st 24 hours), palms should have usual creases & creases should cover the entire sole of the foot, infants should have full ROM, assess Muscle tone by attempting to extend a flexed extremity (check for bilateral symmetry); Grasp Reflex touch the palms or soles of feet near the base of the digits, causing flexion or grasping; Babinski Reflex stroke the outer sole upward from the heel across the ball of the foot causing the big toe to dorsiflex & the others to hyperextend Moro Reflex sudden jarring or change in equilibrium causes sudden extension & abduction of extremities & fanning of fingers w/index finger & thumb forming a C, followed by flexion & adduction of extremities. Barlow’s test checks for broken/dislocated hip & hip dysplacia. Stepping Reflex baby appears to take steps when foot placed on hard surface.