Newborn Assessment and Care

The Normal Newborn
Assessment and Care
PREPARED BY
PERTHA MARIE S. ALVARICO, MSN, RN
Three transition phases
Phase One: the first hour

Phase Two: from one to three hours
Phase Three: from two to 12 hours
Priorities in first hour
Cardiovascular assessment and support

Thermoregulation
Assessment and support of blood glucose
Identification
Observing urinary/meconium passage
Observing for major anomalies and for apparent
gestational age concerns
APGAR ASSESSMENT
One and five minutes

Meant to identify the need for neonatal resucitation
APGAR SCORE
APGAR SCORE
Criteria 0 1 2
Color Blue or pale Acro-cyanotic CompletelyPink
Heart Rate Absent Slow >100/min

(< 100/min)
Reflex irritability No response Grimace Cough, sneeze,

cry
Muscle tone Limp Some flexion Active motion
Respirations Absent Slow, irregular Good, crying

APGAR SCORING
Heart rate – above 100

Respiratory Effort – spontaneous with cry
Muscle tone – flexed with movement
Reflex response – active, prompt cry
Color – pink or acrocyanosis
0-3 infant needs resuscitation

4-7 Gentle stimulation – Narcan
8-10 – no action needed
Additional signs of respiratory distress
Persistant cyanosis
Grunting respirations
Flaring of the nostrils
Retractions
Respiratory rate >60
Heart rate >160 or <110
Ballard’s Assessment/ Scoring
Maintaining thermoregulation
Referred to as maintaining a neutral thermal

environment
 Heat loss is minimal
 Oxygen consumption needs are at their lowest
Hypothermia can cause

 Hypoglycemia
 Increased oxygen needs
Mechanisms of heat loss
Four mechanisms of heat loss
and corresponding interventions
Evaporation
 Dry infant immediately
Conduction
 Place on mothers body skin to skin
Convection
 Cover with a blanket, wear a cap
Radiation
 Keep away from cold windows and cold objects
Vital Sign Normals
97.7-98.6 F (36.5-37 C)
110-160
 A soundly sleeping baby can go to 80 bpm
 A crying baby may be as high as 180
30-60
Voids and Stools
Document from the moment of birth

Urination sometimes missed in early minutes
Generally expect both within the first 24 hours
One really wet diaper per day of age until milk is
fully in.
Observation for Gestational Age
Thorough assessment with Ballard Scale done later

A quick assessment is done in the delivery room
This enables infants earlier admission to the nursery
and anticipatory intervention to the problems of pre
and post term infants
Quick Assessment of Gestational Age
Skin
Vernix
Hair
Ears
Breast tissue
Genitalia
Sole Creases
Resting Posture
Cracked Skin
Abundant Lanugo
Ear of a preterm infant
Areola and increased lanugo
Sole creases
Female genitalia, very preterm
Preterm and Term Genitalia
Male Genitalia
Comparison of resting posture
Preterm and Term Male Genitalia
Hypoglycemia
Criteria vary from source to source

LPN book says <40
RN book says <36 but a threapuetic objective of 45
mg/dl or greater
The brain is dependent on a steady supply of glucose
for its metabolism
Infants at Increased Risk for Hypoglycemia
Preterm/postterm
Infants of diabetic mothers
Large for gestational age
Small for gestational age
Infants with Intrauterine growth retardation
Asphyxiated infants
Infants who are cold stressed
Infants whose Moms took ritodrine or tgerbutaline
to stop preterm labor
Symptoms of Hypoglycemia
Jitteriness Poor suck
Poor muscle tone Feeding difficulties
Sweating High pitched cry
Respiratory difficulty Weak cry
Apnea Lethargy
Low temperature Seizures
Hypoglycemia protocol
Low risk infants have a serum glucose drawn only if

symptomatic
High risk infants will have one per a hospital
protocol
Protocol typically at birth and q 1 hour x 3
Routine Medications
Erythromycin Eye
Ointment
Aquamephyton
(vitamin K)
First Hepatitis B
vaccine
HBIG if Mother is
Hep B surface
antigen positive
Physical Characteristics
DURING PHASES TWO AND THREE

Nervous System: Reflexes
Head lag Rooting reflex
Moro reflex Suck
Rooting Hand and foot grasp
Tonic Neck reflex Babinski
Dancing reflex Trunk incurvation
Magnet reflex Observe for symmetry
Head Lag
Moro Reflex
Tonic Neck Reflex
Dancing Reflex
Suck Reflex
Hand Grasp
Foot Grasp
Early Assessments
 Assess for anomalies

 Head – anterior fontanelle closes 12-18 mo
posterior fontanelle closes 2-3 months
 Neck and clavicles
fracture of clavicle – large infant, lump, tenderness, crepitus,
decreased movement
 Cord
 Extremities
flexed and resist extension
assess fractures, clubfeet
hips
vertebral column
Measurements
Weight – loss of 10% normal

Length
Head and chest circumference
Normal VS
temp 97.7-99.5F axillary
apical pulse 120-160bpm
respirations 30-60/min
A, Measuring the head circumference of the newborn.
B, Measuring the chest circumference of the newborn.
Thermoregulation Assessment
Check soon after birth

Set warmer controls
Take temp q 30 min until stable
Rectal for first temp
Insert only 0.5 inch
Axillary route rest of time
Axillary temperature measurement. The thermometer should
remain in place for 3 minutes
Head
Head circumference
Molding
Caput succedaneum
Cephalohematoma
Fontanelles
 Anterior closes between 12-18 months
 Posterior closes by the end of the 2nd month
Molding
Cehpalhematoma
Caput Succedaneum and Cephalhematoma
Eyes
Eye placement
Epicanthal folds
Blink reflex
Discharge
Pupil reaction
Follows to midline
Hearing
Check overall response to sudden sound

 Moro reflex
Check for placement of ears
 Low set ears may indicate a congenital anomaly
Most infants receive hearing screening within the
first week of life
Respiratory and Cardiovascular
Ongoing assessment of cardio respiratory status that

has occurred since birth
More thorough heart assessment
Murmur may be present until fetal openings have
completely closed however they must be carefully
verified by pediatrician
Femoral and brachial pulses
Abdominal breathing; nose breathers
Femoral Pulses
Brachial Pulses
Assessment of Respiratory Status
Musculoskeletal
Symmetry!!
Five finger and five toes!!!
Clavicles
Movement of arms
Hips for developmental hip dysplasia
Lower legs/feet for “club foot”
Back: curvatures, cysts or dimples
Hip Check
Hip Check Skin Folds
GenitoUrinary
Male or female
Male
 Testes descended
 Proper placement of meatus
Female
 Teach parents about pseudomenstruation
Always watch for and record voids!!!
Gastrointestinal
Passage of meconium
Placement and patency of anus
Abdomen should be soft and non tender
Round but not distended
Bowel sounds are present after first hour of birth
Umbilical cord inspection
Skin, many normal findings
Acrocyanosis
Desquamation
Epstein’s Pearls
Erythema toxicum
Harlequin Color
Milia
Mongolian Spots
Port Wine Stains *
The Normal Newborn
CARE MEASURES FOR THE

NORMAL NEWBORN PLUS A
LITTLE MORE.
Jaundice
Yellow coloring of an infants skin
Common and is caused by the natural breakdown of
RBCs in the infant after birth
Is never considered normal in the first 24 hours.
Physiologic Jaundice
Most jaundice in newborns is physiologic
It peaks between 48-72 hours
Usually disappears within a week
Usually benign
Can become elevated to a point of concern for the
baby
Significance of Jaundice
 Bilirubin is toxic to the brain.
 Bilirubin is prevented from entering the brain by
blood brain barrier under normal circumstances.
 However the blood brain barrier isn’t well developed
in the newborn. Unconjugated bilirubin (lipid
soluble) could cross to the newborn and would cause
encephalopathy. (Kernicterus)
Physiologic Jaundice
Infants have extra RBCs due to fetal life
They need to be broken down by the body
Bilirubin is a component of the degradation of the
RBCs.
The liver is immature and does not conjugate and get
rid of the bilirubin fast enough.
More data on Physiologic Jaundice
RBC/Hgb level is higher than required

 Neonatal RBC: 4.8-7.1 Infant: 4.2-5.2
 Neonatal Hbg 14-24 Infant 11-17
Cells containing fetal hemoglobin have a shorter life
span
Bilirubin Nomogram
Phototherapy Nomogram
Other factors that will exacerbate physiologic
jaundice
Drugs Hypoglycemia
Bruises Hypothermia
Caput Poor feeding
Cephalohematoma Delayed passage
Fetal hypoxia meconium
Polycythemia Trisomy 21
Care to prevent hyperbilirubinemia
Early feeding
Frequent feeding
Neutral thermal environment
Prevention of hypoglycemia
Prevention of hypoxia
Causes of Pathologic Jaundice
Excessive hemolysis
 Rh incompatibility
 ABO incompatibility
 G6PD defficiency
Infection
Metabolic/endocrine abnormalities
Delayed defecation/intestinal obstruction
Liver/biliary disease
Spleen pathology
Polycythemia
PHOTOTHERAPY
Care of Infant on Phototherapy
Risk of injury to eyes
Risk of injury to gonads
Risk of impaired skin integrity
Risk for fluid volume deficiency
Risk for hyperthermai or hypothermia
Risk of neurological injury
Imbalance nutrition
Parental anxiety
Exchange Transfusion
Isn’t he lovely?
Other Newborn Care issues

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The Normal Newborn

Assessment and Care

Phase One: the first hour

Cardiovascular assessment and support

One and five minutes

Color Blue or pale Acro-cyanotic CompletelyPink

Heart Rate Absent Slow >100/min

Reflex irritability No response Grimace Cough, sneeze,

Muscle tone Limp Some flexion Active motion

Respirations Absent Slow, irregular Good, crying

Heart rate – above 100

0-3 infant needs resuscitation

Referred to as maintaining a neutral thermal

Hypothermia can cause

Document from the moment of birth

Thorough assessment with Ballard Scale done later

Criteria vary from source to source

Low risk infants have a serum glucose drawn only if

DURING PHASES TWO AND THREE

 Assess for anomalies

Weight – loss of 10% normal

Check soon after birth

Check overall response to sudden sound

Ongoing assessment of cardio respiratory status that

CARE MEASURES FOR THE

RBC/Hgb level is higher than required

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