NEWBORN

ASSESSMENT

Chetna Sahu
M.Sc. (N) Child Health Nursing
College of Nursing, AIIMS,
Raipur (C.G.)
 RISK FACTORS

An understanding of the maternal/fetal risk

factors is important for the anticipation of
possible problems that the infant may
experience. Risk factors may be divided into
two categories:
• those that can be modified, such as
smoking and drug use,
• and those that are inherent, such as
diabetes and pre-eclampsia.
 IMMEDIATE POST-
BIRTH CARE
• Maintain ABCs
• maintain a warm, or thermoneutral,
environment
• Administration of vitamin K intramuscularly
• Breast feeding
• Care of skin
 Immediate Care of
the Newborn

• Ensure a Patent Airway

– Position on side

– Suction mouth then nares

– supply warmed oxygen if necessary

 Clamping of the Cord
• Cord should be clamped
off about 1” from base of
cord.

• Inspect the cord for

2 arteries and 1 vein.
 Maintain Body
Temperature

• Dry off with prewarm towel

• Skin to skin contact

• Place in warmer if needed

 1. Warm
delivery
10. room
Training/ 2.
Immediate
awarenes drying.
s raising.

9. Warm 3. Skin-to-
resuscitati skin
on. contact.

8. Warm
transporta
tion.
Warm 4. Breast-
feeding.

chain
5. Bathing
7. Mother and
and baby 6. weighing
together. Appropriat postpone
e clothing d
and
7
bedding.
 Phases of Newborn
Assessment
• Immediate assessment with
APGAR score
• The transitional assessment
during period of reactivity
• Physical assessment
• Gestational age assessment
 IMMEDIATE
ASSESSMENT with
apgar scoring
• In 1953, an anesthesiologist named Virginia
Apgar designed a tool for evaluating newborn
infants. The Apgar scores grade the infant's
response to extrauterine life in five categories
• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability
• Color
 APGAR Score
SIGN SCORE-0 SCORE-1 SCORE-2
Heart Rate Absent Slow,<100 >100

Respiratory Absent Irregular, slow Good Strong Cry.

Effort weak cry.

Muscle tone Limp Some Flexion of Well Flexed.

Extremities
Reflex No Response Grimace. Cry, Sneeze.
irritability
Colour Blue, Pale Body pink, Completely pink.
Extremities Blue
 APGAR scoring
is done in
1 & 5 min
• Total score of 0-3 represent severe distress ,
• Score of 4-6 signify moderate difficulty,
• Score of 7-10 absence of difficulty in
adjusting to extra-uterine life.
 Score This !

• Baby girl Iva has a heart rate of 102,

with slow, irregular respirations. She
grimaces when stimulated. She has
some flexion in her extremities and her
skin color is pale.

• What is her Apgar Score?

 2+1+1+1+0 = 05
SIGN SCORE-0 SCORE-1 SCORE-2
Heart Rate Absent Slow,<100 >100

Respiratory Absent Irregular, slow Good Strong Cry.

Effort weak cry.

Muscle tone Limp Some Flexion of Well Flexed.

Extremities
Reflex No Response Grimace. Cry, Sneeze.
irritability
Colour Blue, Pale Body pink, Completely pink.
Extremities Blue
 TRANSITIONAL
ASSESSMENT
• Assessment of newborn’s behavior during
first 24 hours.
• Neonate tries to cope-up with extra-uterine
life
• Various changes in vital function occurs & is
known as period of reactivity.
a) First period of reactivity (6 to 8 hours)
b) Second period of reactivity
 The first period of
reactivity
• generally lasts 6 to 8 hours.
• For the first 30 minutes after birth, the newborn is generally very
alert and active.
• The infant will usually have a vigorous suck reflex during this time,
and it is generally an excellent time to begin breastfeeding.
• The infant will have open eyes and will be interested in looking
around.
• Physiologically, the infant's respiratory rate may be increased and
the lungs will sound quite wet.
• The heart rate may be increased, bowel sounds are active,
mucous production is increased, and body temperature may be
slightly decreased
• After this initial period of alertness, the newborn will go into
a deep sleep that generally lasts from 2 to 4 hours, though it
may continue much longer.
• During this period, the infant is very calm. Attempts to
stimulate the infant will generally be unsuccessful.
• Ideally, the physical examination should be completed
before this time and the infant can then be left alone to
sleep. Physiologically, the infant will experience a decrease
in respiratory rate, mucous production, and temperature
and will likely not void or stool
 The second period
of reactivity
• Which usually lasts 2 to 5 hours, begins when the
newborn wakes from this deep sleep state.
• The infant is generally very alert once again and showing
signs of hunger.
• This is an excellent opportunity for the infant and family
to interact with each other and for the nurse to begin
some teaching regarding hunger cues and other ways
that the infant may communicate needs.
• Physiologically, the newborn's heart and respiratory rates
increase, the gag reflex is active, and the production of
mucous and meconium resumes
 PHYSICAL
ASSESSMENT
• General Guide lines for conducting a physical examination
are:-
• Provide a normothermic and non- stimulating examination
area.
• Undress only body area to be examined to prevent heat loss.
• Proceed in an orderly sequence(usually head to toe) with
following exceptions-
▪ Perform all procedures that require quiet first such as
auscultating the lungs heart and abdomen.
▪ Perform disturbing procedures such as testing reflexes, last.
▪ Measure head, chest and length at same time to compare to
compare results.
 Contd….

• Proceed quickly to avoid stressing infants.

– Check that equipment and supplies are
working properly and are accessible.
• Comfort infant during and later
examination, Involve parent in the following
- Talk softly.
- Hold infants hand against chest.
- Swaddle and hold.
- Guide pacifier and gloved finger to suck.
 Identification of the
Newborn
▪ Mother and infant should have
matching “identitybands”.

▪ Bands should be placed on infant prior to

leaving the delivery room

▪ Footprint of infant and fingerprint of the

mother
 PHYSICAL EXAMINATION
ARE CARRIED OUT AS
• Anthropometric measurements-
• Head circumference- 33 to 35 cm, about 3 cm
larger than chest Circumference.
• Chest Circumference- 3 cm less than the head
circumference.
• Crown to rump length- 31 to 35 cm
approximately equal to head circumference.
• Head to Heal Length- 50 ± 2cm
• Birth Weight- 2500 - 3000gm (6-9 pounds).
 VITAL SIGNS

• Temperature-
- Axillary 36.5 °c - 37°c (97.9°F - 98°F)
- Crying may increase body temperature
slightly.
- Radiant warmer will falsely increase body
temperature.
 Abnormal
(Possible causes)

• Decreased: cold environment,

hypoglycaemia, infection, CNS problem

• Increased: infection, environment too

warm
• Heart Rate-
- Apical 120- 140 beats / min. (assess pulse- femoral,
brachial, pedal )
- Crying will increase heart rate.
- Sleep will decrease heart rate.
- During the period of reactivity (6-8 hours) rate can
reach 180 beats / min
- PMI (point of maximal impulse) at 3rd – 4th intercostal
space
 Abnormal
(Possible causes)
• Tachycardia: respiratory problems,
anemia, infection, cardiac conditions
• Bradycardia: asphyxia, increased ICP
• PMI to right : dextrocardia, pneumothorax
• Murmurs: functional or congenital heart
defects
• Dysrhythmias: absent or unequal pulses
(coarctation of aorta)
 RESPIRATORY

• Before birth O2 needs met by placenta

• L/S ratio should be 2:1
• After delivery need mature lungs that are vascularized,
have surfactant and sacules - usually adequate by 32-35
weeks- at term the lungs hold approx. 20-30 ml of fluid/kg
• What initiates respiration?
• Respiration rate: 40-60/min
• Shallow & unlabored.
• Chest movement symmetric, breath sounds present &
clear bilaterally
 Abnormal
(Possible causes)
• Tachypnea, especially after the first hour
• Slow respiration (maternal medication,
distress)
• Asymmetry or decreased chest expansion
(pneumothorax)
• Moist, coarse breath sounds rales,
crackles, rhonchi, fluid in lungs)
• Bowel sounds in chest (diaphragmatic
hernia)
 Periodic Breathing -vs-
Apnea
• Apnea: no breathing for periods of greater
than 15 seconds should be evaluated.
Notify physician if resp < 30 or > 60
 Assessment of
Respiratory Status
 Downes Scoring system
0 1 2

Cyanosis None In room air In 40% FIO2

Retractions None Mild Severe

Audible with Audible without

Grunting None
stethoscope stethoscope

Air entry Clear Decreased or delayed Barely audible

Respiratory
Under 60 60-80 Over 80 or apnea
rate
Score:

> 4 = Clinical respiratory distress; monitor arterial blood gases

> 8 = Impending respiratory failure
 Cry
• Should be vigorous, medium pitched
• Piercing cry from :
Hypoglycemia
Neurological disorders
Sepsis
Withdrawal
• General appearance-
Posture –Flexion of hand and extremities
which rest on chest and abdomen .
Comparison of
resting posture
 SKIN-
Assessment Normal finding Abnormal
finding
Note the skin At Birth- Bright Acrocyanosis-
color and lesion red , puffy , Cyanosis of hands
smooth. and feet .
Second to 3RD day Color- cyanosis,
– Pink flaky ,Dry . jaundice, pallor, etc.
Vernix caseosa.
Lanugo .

• Edema around eyes , face ,legs dorsa of hands

, feet and scrotum or labia.
General description of the skin

37
Acrocyanosis

38
1. Vernix Caseosa: Soft yellowish cream layer

that may thickly cover the skin of the

newborn, or it may be found only in the body

creases and between the labia.

The debate of wash it off or to keep it.

39
Vernix Caseosa

40
2. Lanugo hair:

- Distribution

- The more premature baby is, the heavier the

presence of lanugo is.

- It disappears during the first weeks of life

41
 Lanugo hair

Term baby preterm baby

42
 3. Mongolian spots:
Bluish black coloration on the lower back, buttocks,
anterior trunk, & around the wrist or ankle. They are
not bruise marks or a sign of mental retardation,
they usually disappear during preschool years
without any treatment.
They are caused by some pigment that didn't make
it to the top layer when baby's skin was being
formed. 43
Mongolian spots

44
Mongolian spots

45
4. Desquamation:

- Peeling of the skin over the areas of bony

prominence that occurs within 2-4 weeks of life

because of pressure and erosion of sheets.

46
Desquamation

47
5. Physiological Jaundice:
6. Milia:
- Small white or yellow pinpoint spots.
- Common on the nose, forehead, & chin
of the newborn infants due to accumulations of
secretions from the sweat & sebaceous glands
that have not yet drain normally.
They will disappear within 1-2 weeks, they
48
should not expressed.
Physiological Jaundice

49
Physiological Jaundice

50
Milia

51
 Cutis Memorata – Transient mottling
when infant is exposed to decreased
temperature , stress or over stimulation.
 HEAD-

• Anterior Fontenelle - Diamond Shaped , 2.5 –

4cm (1-1.75 inch ).
• Posterior Fontanelle –Triangular , 0.5 -1 cm (
0.2 – 0.4 inch ).
• -Fontenelle should be flat , soft and firm .
• -Widest part of fontenelle measured from
bone to bone , not suture to suture .
• Palpate fontanelle
• Anterior fontanelle • posterior fontanelle
Molding of infant's head.
Molding- over-riding sutures
 Caput succedaneum

• An edematous swelling on the presenting portion

of the scalp of an infant during birth, caused by
the pressure of the presenting part against the
dilating cervix. The effusion overlies the
periosteum with poorly defined margins.
• Caput succedaneum extends across the midline
and over suture lines. Caput succedaneum does
not usually cause complications and usually
resolves over the first few days. Management
consists of observation only.
58
Caput succedaneum

59
Caput succedaneum

60
Caput succedaneum

61
Cephalhematoma:
Cephalhematoma is a subperiosteal collection
of blood secondary to rupture of blood vessels
between the skull and the periosteum, in which
bleeding is limited by suture lines (never cross
the suture lines).

62
Cephalhematoma

63
Cephalhematoma

64
• Caput succedaneum • Cephalahematoma
• crosses suture line • does not cross suture
 FACE

• Should be assessed for Symmetry,

paralysis, shape, swelling etc
• Any congenital disorder
 Observe shape & size of mouth,
size of jaw
• Jaw molding
• micrognathia-
small jaw
 EARS -
• Position – Top of pinna on horizontal line with outer
canthus of eye .
Symmetry
Low set r/t Down’s, mental retardation, renal
problems
• Startle reflex elicited by a loud , sudden noise .
Respond to sound, Habituation
• Pinna flexible ,
• Hearing Test
 Cartilage

Term Preterm
• Ear tag • Lop ear
• Microtia, small ear
 EYES

• Bluish white sclera, pupils gray in color. True color is

not determined until the age of 3-6 months.
• Check reflexes
• Doll eyes, Blinking reflex, Can not follow an object
(Rudimentary fixation on objects).
• Tearless
• Some visual acuity
• Usually edematous eye lids
• Pupil: React to light
• Absence of tears
Normal Eye

73
Eyelid Edema

74
Dysconjugate Eye Movements

75
Subconjunctival Hemorrhage

76
Congenital Glaucoma

77
Purulant discharge &
swollen eye lid in
gonorrhea and
Chlamydia
• Hypertelorism • Iris cyst
Cataract
 NOSE-

• Nasal patency .
• Symmetry
• Nasal Discharge – Thin white mucus .
• Sneezing .
Normal Nose

82
Dislocated Nasal Septum/
deviated nasal septum

83
 Any congenital defect-
• depressed nose
• dacrocystocele1 bridge (which is
indicative of
Down’s syndrome)
 MOUTH & THROAT
• Assess sucking, swallowing, gag reflex.
• Uvula in midline .
• Absent or minimal salivation
• Check palate for any deformity
• Oral thrush
Epstein Pearls & cheeks

86
Cleft Palate

87
Cleft Lip

88
Cheeks: Have a chubby appearance
due to development of fatty sucking pads

that help to create negative pressure

inside the mouth which facilitates

sucking.
89
Gum: May appear with a quite irregular edge.

Sometimes the back of gums contain whitish

deciduous teeth that are semi-formed, but not

erupted

90
Irregular edges with Natal Teeth

91
Natal Tooth

92
Normal Tongue Ankyloglossia

93
Ankyloglossia (tongue tie)

94
 NECK –

• Short thick neck, usually surrounded by

skin folds . Sometimes associated with
widely separated nipple.
• Tonic neck reflex .
• Short neck with other anomaly
 CHEST-
• Anterio- posterior and lateral diameters
equal.
• Xiphoid process evident.
• Milky discharge from nipples.
• Abnormal respiration sounds.
• Intercostals • Breast
retraction enlargement.
In this infant, the antero-posterior (AP) diameter appears greater
than normal, and there was concern that the AP diameter of the
left chest was greater than that on the right. (Notice the white
lead on the right nipple and the gold lead over the midline) This
finding is suspicious for pnuemothorax, which can occur
spontaneously in well newborns. Congenital diaphragmatic hernia
may present with an abdomen that appears flat relative to the
chest (scaphoid abdomen), but in that case severe respiratory
distress would be expected.
 LUNGS-
• Respirations chiefly abdominal.
• Cough reflex absent at birth , present by 1-
2 days in term infant .
• Bilateral equal bronchial breath sounds.

• Apex- Fourth to fifth inter-coastal space

,lateral to left sterna boarder .
 ABDOMEN –
• Cylindric in shape .
• Liver- Palpable 1-3 cm below right coastal
margin.
• Spleen - Tip palpable at end of 1st week of
age .
• Kidneys- Palpable 1-2 cm above umbilicus
• Femoral pulses – Equal bilaterally.
• Umblical Cord- Bluish –white at birth with
two arteries and one vein . Made of
wharton’s jelly
• umbilical hernia
• Normal umbilical • Meconium stained
cord umbilical cord
• normal cord has two arteries (small, round
vessels with thick walls) and one vein (a
wide, thin-walled vessel that usually looks
flat after clamping).
Normal cord with intravascular clots Cord after 19 hours

Dry cord After shading

• Omphalitis umbilical
hematoma
Cord hemangioma can be quite
serious. Large hemangiomas can
comprise the vasculature or
completely obstruct flow in the
cord in utero or lead to high
output cardiac failure. Fetal
• Wharton's jelly cyst
deaths have been reported.
Also known as a "false
cyst" of the cord, is an
area where liquefaction of
the jelly has occured. Up
to 20% of infants with this
condition have associated
anomalies.
 Gastrointestinal System

• Immature at birth, reaches maturity at 2-3

years of age
• place food at back of tongue
• sucking becomes coordinated @32 wks
• little saliva until 3 months of age
• bowel sounds after 1 hour of birth
 Gastrointestinal (continued)

• NB have difficulty digesting complex

starches and fat
• Abdomen becomes easily distended after
eating
• Initial fecal material = meconium
• No normal flora at birth in GI system to
synthesize Vit. K
 HEPATIC FUNCTION

• Liver produces substances essential for

clotting of blood.
• Stores needed iron for the first few
months. Preterm & small infants have lower iron stores than
full term and heavier infants. (full term infants stores last 4-6 mo)

• NB at risk for Physiologic Jaundice after

24 hours of age, d/t increased breakdown
of RBC’s and immature liver functioning.
 Increased Bilirubin Levels

• Jaundice in the 1st day is NOT normal

• Bilirubin level greater than 12 at any time
needs further attention
• Maternal causes of increased bilirubin
levels in the NB: epidural use, oxytocin
induced labor, infection, hepatitis
• Ethnic Influences: Asian infants levels
may be double other ethnic groups.
 Kernicterus

• Complication of neonatal
hyperbilirubinemia --> encephalopathy
• basal ganglia and other areas of the brain
and spinal card are infiltrated w/ bilirubin
(produced by the breakdown of
hemoglobin -> levels of 20 - 25 or more).
• Poor prognosis if untreated.
 GENITOURINARY SYSTEM

KIDNEYS AND URINATION

• 92% of all healthy infants void in the first
24 hrs of birth
• initial urine:cloudy, scant amounts, uric
acid crystals-> reddish stain on diaper
• Kidneys not fully functional until child is 2
years of age.
 FEMALE GENITALIA-

• Labia and Clitoris

usually edematous.
• Uretheral meatus
behind clitoris .
• Vernix caseosa
between labia.
• Urination within 24
hours .
• Normal female • Hymenal tag
genitalia
 MALE GENITALIA
• Uretheral opening at tip of
glans penis .
• Testes palpable in scrotum .
• Scrotum usually large ,
edematous , pendulus and
covered withrugae ,usually
deeply pigmented in dark –
skinned ethnic group
• Smegma .
• Urination within 24 hours .
 • Epispedias with
• Hypospedias extrophy of bladder
(ectopia vesica)
• Chordee
• Hydrocele • Inguinal hernia
• Inguinal or • Undescended testis
descending testicle
• Ambiguous genitalia • Ambiguous genitalia
• Male • female
 BACK AND RECTUM –
• Spine intact , no openings , masses or
prominent curves .
• Trunk incurvation reflex .
• Anal reflex .
• Patent and opening .
• Passage of meconium within 48 hours of
birth .
• Sacral dimple • Sacral skin tag
Skin tags in the
sacral area are also
potential indicators
of spinal dysraphism
• myelomeningocele
 EXTREMITIES:-
• Ten fingers and toes .
• Full range of motion(ROM).
• Nail beds pink with transient cyanosis
immediately after birth.
• Sole usually flat.
• Symmetry of extremities Equal muscle tone
bilaterally , especially resistance to apposing
flexion .
• Equal bilateral brachial pulses.
• Normal palm • Transverse palm
Creases crease
• Club foot severe syndactyly
• polydactyly • Syndactyly
 NEUROLOGICAL REFLEXES
• Primary reflexex
• Hypotonia
 WEIGHT LOSS

• It is normal for the newborn infant to loose 5-

10% of weight in the first 4 to 5 days of life.
 INFANTS AT RISK

“RED FLAGS” after birth include:

• gagging --> turning blue (esp. after fdg)
• generalized cyanosis
• weak cry
• grunting or respiratory distress
• decreased or absent movements
• excessive twitching or trembling
• OTHERS>>>>>
 The following findings are
considered warning signs that
may be seen during the general
assessment

• Axillary temperature less than 36.1°C or greater than

37.2°C
• Heart rate less than 100 bpm or greater than 160 bpm
• Respiratory rate less than 30 or greater than 60 breaths
per minute
• Jaundice
• Periods of apnea lasting more than 15 seconds
• Lack of movement or responsiveness
• Hypotonic or hypertonic position
• Lack of interest in environment
• WARNING SIGNS
• Warning signs of the skin assessment that would warrant
further investigation and/or immediate intervention include:
• Long nails and desquamation, indicating postmaturity
• Thin translucent skin with abundant vernix and lanugo,
indicating prematurity
• Pallor, possibly caused by hypothermia, anemia, sepsis, or
shock
• Cyanosis, possibly caused by cardiorespiratory disease,
hypoglycemia, polycythemia, sepsis, or hypothermia
• Petechiae, possibly caused by thrombocytopenia, sepsis,
congenital infection, or pressure sustained during delivery
• Plethora, possibly caused by polycythemia
• Meconium staining, possibly caused by intrauterine asphyxia
• Abnormal hair distribution or extra skin folds, possibly
associated with genetic abnormalities
• Poor skin turgor associated with intrauterine growth
retardation and hypoglycemia
• Large hemangiomas, which may trap platelets within their
borders and cause thrombocytopenia
• Bullae or pustules, possibly caused by staphylococcal
infection
 NURSING DIAGNOSIS:

• Ineffective Airway Clearance R/T excessive

oropharyngeal mucus
• Ineffective Thermoregulation R/T newborn
transition to extrauterine life
• High Risk for infection R/T maturational
factors, immature immune system
• PC: Hypoxemia PC: Hyperbilirubinemia
• (W) Beginning Integration of NB into Family
Unit
THANK YOU