Nb AssessmentDesk 21-2 SUMMARY OF NEWBORN ASSESSMENT *MCH pages 479-473| NORMAL| ABNORMAL (POSSIBLE CAUSES)| NURSING CONSIDERATIONS| Preliminary AssessmentAssess for apparent issues first. If toddler is secure and has no issues that require instant consideration, proceed with full evaluation. | Very important Indicators| TemperatureAxillary: 36. 5– 37. 5°C (97. 7 – 99. 5°F). Axilla is most well-liked website. | Decreased (chilly setting, hypoglycemia, an infection, CNS downside). Elevated (an infection, setting to heat). | Decreased: Institute warming measures and test in 30 minutes. Examine blood glucose. Elevated: the extreme clothes.
Examine for dehydration. Decreased or elevated: search for indicators of an infection. Examine radiant hotter or incubator temperature setting. Examine thermometer for accuracy if pores and skin is heat or cool to the touch. Report irregular temperature to doctor. | PulsesHeart fee 120 – 160 BPM. (100 sleeping, 180 crying). Rhythm common. PMI at Third-4th intercostal house lateral to mid-clavicular line. Brachial, femoral, and pedal pulses current and equal bilaterally. | Tachycardia (respiratory issues, anemia, an infection, cardiac circumstances). Bradycardia (asphyxia, elevated intracranial stress).
PMI to proper (dextrocardia-heart located to proper of physique, pneumothorax). Murmurs (regular or congenital coronary heart defects). Dysrhythmias. Absent or unequal pulses (coarctation of the aorta). | Word location of murmurs. Refer irregular charges, rhythms and sounds, pulses. | RespirationsRate 30 -60 (AVG 40 -49) BrPM. Respirations irregular, shallow, unlabored. Chest actions symmetric. Breath sounds current and clear bilaterally. | Tachypnea, particularly after the primary hour (respiratory misery). Gradual respirations (maternal medicines). Nasal flaring (respiratory misery). Grunting (respiratory misery syndrome).Gasping (respiratory melancholy). Intervals of apnea greater than 20 seconds or with change in coronary heart fee or coloration (respiratory melancholy, sepsis, chilly stress). Asymmetry or decreased chest enlargement (pneumothorax). Intercostal, xiphoid, supraclavicular retractions or see-saw (paradoxical) respirations (respiratory misery). Moist, coarse breath sounds (crackles, rhonchi) (fluid within the lungs). Bowel sounds in chest (diaphragmatic hernia). | Gentle variations require continued monitoring and often clear early hours after delivery. If persistent or greater than delicate, suction, give oxygen, name doctor, and provoke extra intensive care. Blood Stress Varies with age, weight, exercise, and gestational age. Common systolic 65-95 mm Hg, common diastolic 30-60 mm Hg. | Hypotension (hypovolemia, shock, sepsis). BP 20 mm Hg or increased in arms than legs (coarctation of the aorta). | Refer irregular blood pressures. Put together for intensive care and really low. | Measurements| Weight2500-4000 g (5 lbs. Eight oz. to eight lbs. 13 oz. ). Weight reduction as much as 10% in early days. | Excessive (low gestational age LGA, maternal diabetes). Low (small for gestational age SGA, preterm, multifetal being pregnant, medical circumstances and mom that affected fetal progress).
Weight reduction above 10% (dehydration, feeding issues). | Decide causeMonitor for problems widespread to trigger. | Size48-53 cm (19-21 inches)| Beneath regular (SGA, congenital dwarfism). Above regular (LGA, maternal diabetes). | Decide causeMonitor for problems widespread to trigger. | Head Circumference32-38 cm (12. 5-15 inches). Head and neck are roughly ? of infants physique floor. | Small (SGA, microcephaly, anencephaly-absence of enormous a part of mind or cranium). Giant (LGA, hydrocephalus, elevated intracranial stress). | Decide causeMonitor for problems widespread to trigger. | Chest Circumference30-36 cm (12-14 inches).
Is 2 cm lower than head circumference. | Giant (LGA). Small (SGA). | Decide causeMonitor for problems widespread to trigger. | Posture Flexed extremities transfer freely, resist extension, return shortly to flexed state. Palms often clenched. Actions symmetric. Slight tremors on crying. Breech: prolonged, stiff legs. “Molds” physique to caretaker’s physique when held, responds by quieting when wants met. | Limp, flaccid, floppy, or inflexible extremities (preterm, hypoxia, medicines, CNS trauma). Hypertonic (neonatal abstinence syndrome, CNS harm). Jitteriness or tremors (low glucose for calcium stage).
Opisthotonos- excessive hyperextension of physique, seizures, stiff when held (CNS harm). | Search trigger, refer abnormalities. | CryLusty, sturdy. | Excessive-pitched (elevated intracranial stress). Week, absent, irritable, cat-like “mewing” (neurologic issues). Hoarse or crowing (laryngeal irritation). | Observe for adjustments in report abnormalities. | Skincolor pink or tan with acrocyanosis (cyanotic discoloration of extremities). Vernix caseosa in creases. Small quantities of lanugo (effective,comfortable downy hair) over shoulders, sides of face, brow, higher again. Pores and skin turgor good with fast recoil. Some cracking and peeling of pores and skin.
Regular variations: Milia (tiny white bumps). Pores and skin tags. Erythema toxicum (flea chew” rash). Puncture on scalp (from electrode). Mongolian spots. | Coloration: cyanosis of mouth and central areas (hypoxia). Facial bruising (nuchal twine). Pallor (anemia, hypoxia). Grey (hypoxia, hypotension). Purple, sticky, clear pores and skin (very preterm). Greenish brown discoloration of pores and skin, nails, twine (doable fetal compromise, postterm). Harlequin coloration (regular transient autonomic imbalance). Mottling (regular or chilly stress, hypovolemia, sepsis). Jaundice (pathologic if first 24h). Yellow vernix (blood incompatibilities). Thick vernix (preterm).
Supply Marks: bruises on physique (stress), scalp (vacuum extractor), or face (twine round neck). Petechiae (stress, low platelet rely, an infection). Forceps marks. Birthmarks: Mongolian spots. Nevus simplex (salmon patch,” stork chew”). Nevus flammeus (port-wine stain). Nevus vasculosus (strawberry hemangioma). Cafe au lait spots (6+) bigger than zero. 5cm in measurement (neurofibromatosis). Different: extreme lanugo (preterm). Extreme peeling, cracking (postterm). Pustules or different rashes (an infection). “Tenting” of pores and skin (dehydration). | Differentiate affected person bruising from cyanosis. Central cyanosis requires suction, oxygen and additional therapy.
Refer jaundice in first 24 hours or extra intensive than anticipated for age. Look ahead to respiratory issues in infants with meconium staining. Search for indicators and problems of preterm or postterm delivery. File location, measurement, form, coloration, kind of rashes and marks. Differentiate Mongolian spots from bruises. Examine for facial motion with forceps marks. Look ahead to jaundice with bruising. Level out and clarify regular pores and skin variations to folks. | Head Sutures palpable with small separation between every. Anterior fontanel diamond formed, Four-5 cm, comfortable and flat. Many bulge barely with crying. Posterior fontanel triangular, zero. 5-1 cm.
Hair silky and comfortable with particular person hair strands. Regular variations: overriding sutures (molding). Caput succedaneum or cephalohematoma (stress throughout delivery). | Head massive (hydrocephalus, elevated intracranial stress) or small (microcephaly). Extensively separated sutures (hydrocephalus) or exhausting, ridged space at sutures (craniosynostosis- delivery defect that causes a number of sutures on a child's head to shut sooner than regular). Anterior fontanel depressed (dehydration, molding), full or bulging at relaxation (elevated intracranial stress). Woolly, bunchy hair (preterm). Uncommon hair progress (genetic abnormalities). | Search reason for variations.
Observe for indicators of dehydration with depressed fontanel; elevated intracranial stress with bulging of fontanel and broad separation of sutures. Refer for therapy. Differentiate Caput succedaneum from cephalohematoma, and reassure mother and father of regular end result. Observe for jaundice with cephalohematoma. | Ears Ears well-formed and full. Space the place higher ear meets head even with imaginary line drawn from outer canthus of eye. Startle response to loud noises. Alerts to high-pitched voices. | Low set ears (chromosomal issues). Pores and skin tags, pre-auricular sinuses, dimples (could also be related to kidney or different abnormalities).
No response to sound (deafness). | Examine voiding if ears irregular Search for indicators of chromosomal abnormality if place irregular. Refer for analysis if no response to sound. | FaceSymmetric and look and motion. Elements proportional and appropriately positioned. | Asymmetry (stress imposition in utero). Drooping of mouth or one facet of face,” one-sided cry” (facial nerve harm). Irregular look (chromosomal abnormalities). | Search reason for variations. Examine supply historical past for doable reason for harm to facial nerve. | Eyes Symmetric. Eyes clear. Transient strabismus. Scant or absent tears.
Pupils equal, react to mild. Alerts to fascinating sights. Doll’s eye sign- reflex motion of the eyes in the wrong way to that which the top is moved, the eyes being lowered as the top is raised, and the reverse (Cantelli signal); a sign of practical integrity of the brainstem tegmental pathways and cranial nerves concerned in eye motion. Purple reflex present- reddish-orange reflection of sunshine from the eye's retina. Might have subconjunctival hemorrhage or edema of eyelids from stress throughout delivery. | Irritation or drainage (chemical or infectious conjunctivitis). Fixed tearing (plugged lacrimal duct).
Unequal pupils. Failure to comply with objects (blindness). White areas over pupils (cataracts). Setting solar sign- downward deviation of the eyes so that every iris seems to “set” beneath the decrease lid, with white sclera uncovered between it and the higher lid; indicative of elevated intracranial stress or irritation of the mind stem. (hydrocephalus). Yellow sclera (jaundice). Blue sclera (osteogenesis imperfecta- situation inflicting extraordinarily fragile bones). | Clear and monitor any drainage; search trigger. Reassure mother and father that subconjunctival hemorrhage and edema will clear. Refer different abnormalities. NoseBoth nostrils open to air move. Might have slight flattening from stress throughout delivery. | Blockage of 1 or each nasal passages (choanal atresia). Malformations (congenital circumstances). Flaring, mucus (respiratory misery). | Observe for respiratory misery. Report malformations. | Mouth Mouth, gums, tongue pink. Tongue regular in measurement and motion. Lips and palate intact. Sucking pads. Sucking, rooting, swallowing, gag reflexes current. Regular variations: precocious enamel, Epstein’s pearls-A number of small white epithelial inclusion cysts discovered within the midline of the palate in most newborns. Cyanosis (hypoxia). White patches on cheek or tongue (candidiasis). Protruding tongue (Down syndrome). Diminished motion of tongue, drooping mouth (facial nerve paralysis). Cleft lip, palate or each. Absent or weak reflexes (preterm, neurologic downside). Extreme drooling (tracheoesophageal atresia). | Oxygen for cyanosis. Count on unfastened enamel to be eliminated. Receive order for antifungal medicine for candidiasis. Examine mom for vaginal or breast an infection. Refer anomalies. | Feeding Good suck/swallow coordination. Retains feedings. | Poorly coordinated suck and swallow (prematurity).
Duskiness or cyanosis throughout feeding (cardiac defects). Choking, gagging, extreme drooling (tracheoesophageal fistula, esophageal atresia). | Feed slowly. Cease steadily if issue happens. Suction and stimulate if obligatory. Refer infants with continued issue. | Neck/Clavicles Quick neck turns head simply facet to facet. Toddler raises head when susceptible. Clavicles intact. | Weak spot, contractures, or ridgidity (muscle abnormalities). Webbing of neck, massive fats pad at again of neck (chromosomal issues). Crepitus, lump, or crying when clavicle or different bones palpated, diminished or absent arm motion (fractures). Fracture of clavicle extra frequent in massive infants with shoulder dystocia at delivery. Immobilize arm. Search for different accidents. Refer abnormalities. | Chest Cylinder form. Xiphoid course of could also be outstanding. Symmetric. Nipples current and positioned correctly. Might have engorgement, white nipple discharge (maternal hormone withdrawal). | Asymmetry (diaphragmatic hernia, pneumothorax). Supernumerary nipples. Redness (an infection). | Report abnormalities. | Stomach Rounded, comfortable. Bowel sounds current inside first hour after delivery. Liver palpable 1-2cm beneath proper costal margin. Pores and skin intact. Three vessels in twine. Clamp tight and twine drying.
Meconium handed inside 12-48hr. Urine usually handed inside 12-24h. Regular variation: “Brick mud” staining of diaper (uric acid crystals). | Sunken stomach (diaphragmatic hernia). Distended stomach or loops of bowel seen (obstruction, an infection, and enormous organs). Absent bowel sounds after first hour (paralytic ileus). Lots palpated (kidney tumors, distended bladder). Enlarged liver (an infection, coronary heart failure, hemolytic illness). Belly wall defects (umbilical or inguinal hernia, omphalocele, gastroschisis, exstrophy of bladder). Two vessels in twine (different anomalies). Bleeding (unfastened clamp). Redness, drainage from twine (an infection).
No passage of meconium (imperforate anus, obstruction). Lack of urinary output (kidney anomalies) or insufficient quantities (dehydration). | Refer abnormalities. Assess for different anomalies if solely two vessels in twine. Tighten or change unfastened twine clamp. If stool and urine output irregular, search for missed recording, improve feedings, report. | Genitals| Feminine Labia majora darkish, cowl clitoris and labia minora. Small quantity of white mucus vaginal discharge. Urinary meatus and vagina current. Regular variations: Vaginal bleeding (pseudomenstruation). Hymenal tags. | Clitoris and labia minora bigger than labia majora (preterm).
Giant clitoris (ambiguous genitalia). Edematous labia (breech delivery). | Examine gestational age for immature genitalia. Refer anomalies. | Male Testes inside scrotal sac, rugae on scrotum, prepuce nonretractable. Meatus at tip of penis. | Testes in inguinal canal or stomach (preterm, cryptorchidism). Lack of rugae on scrotum (preterm). Edema of scrotum (stress in breech delivery). Enlarged scrotal sac (hydrocele). Small penis, scrotum (preterm, ambiguous genitalia). Empty scrotal sac (cryptorchidism). Urinary meatus positioned on higher facet of penis (epispadias), underside of penis (hypospadias, or perineum.
Ventral curvature of the penis (chordee). | Examine gestational age for immature genitalia. Refer anomalies. Clarify to folks why no circumcision will be carried out with irregular placement of meatus. | Extremities| Higher and Decrease ExtremitiesEqual and bilateral motion of extremities, Right quantity and formation of fingers and toes. Nails to ends of digits or barely past. Felxion, good muscle tone. | Crepitus, redness, lumps, swelling (fracture). Diminished or absent motion, particularly throughout Moro reflex (fracture, nerve harm, paralysis). Polydactyly (additional digits). Syndactyly (webbing) Fused or absent digits.
Poor muscle tone (preterm, neurologic harm, hypoglycemia, and hypoxia). | Refer all anomalies, search for others. | Higher ExtremitiesTwo transverse palm creases. | Simian crease (regular or Down syndrome). Diminished motion (harm). Diminished motion of arm with extension and forearm susceptible (Erb-Duchenne paralysis). | Refer all anomalies, search for others. | Decrease Extremities Legs equal in size, abduct equally, gluteal and thigh creases and knee peak equal, no hip “clunk”. Regular place of ft. | Ortolani and Barlow exams irregular, unequal leg size, unequal thigh or gluteal creases (developmental dysplasia of the hip).
Malposition of ft (place in utero, talipes equinovarus). | Refer all anomalies, search for others. Examine malpositioned ft to see if they are often gently manipulated again to regular place. | BackNo openings noticed or felt in vertebral column. Anus patent. Sphincter tightly closed. | Failure of a number of vertebrae to shut (spina bifida), with or with out sac with spinal fluid and meninges (meningocele) or spinal fluid, meninges, and twine (myelomeningocele), enclosed. Tuft of hair over spina bifida occulta. Pilondial dimple or sinus. Imperforate anus. | Refer abnormalities.
Observe for motion beneath stage of defect. If sac, cowl with sterile dressing moist with sterile saline. Defend from harm. | Reflexes See desk 21-Three. | Absent, uneven or weak reflexes. | Observe for indicators of fractures, nerve harm, or harm to CNS. | TABLE 21-Three SUMMARY OF NEONATAL REFLEXES *MCH web page 493| REFLEX| METHOD OF TESTING| EXPECTED RESPONSE| ABNORMAL RESPONSE/POSSIBLE CAUSE| TIME REFLEX DISAPPEARS| Babinski| Stroke lateral sole of foot from heel to throughout base of toes. | Toes flare with dorsiflexion of the large toe. | No response. Bilateral: CNS deficit. Unilateral; native nerve harm. Eight-9 mos| Gallant (trunk incurvation)| With toddler susceptible, evenly stroke alongside the facet of the vertebral column. | Whole trunk flexes towards facet stimulated. | No response: CNS deficit. | Four mos| Grasp reflex (palmar and plantar)| Press finger in opposition to of toddler’s fingers or toes. | Fingers curl tightly; toes curl ahead. | Weak or absent: neurologic deficit or muscle harm. | Palmar grasp: 2-Three mos. Plantar grasp: Eight-9 mos| Moro| Let toddler’s head drop again approx. 30?. | Sharp extension and abduction of arms adopted by flexion and adduction to “embrace” place. | Absent: CNS dysfunction.
Assymetry: brachial plexus harm, paralysis, or fractured bone of extremity. Exaggerated: maternal drug use. | 5-6 mos| Rooting| Contact or stroke from facet of mouth towards cheek. | Toddler turns head to facet touched. Troublesome to illicit if toddler is sleeping or simply fed. | Weak or absent: prematurity, neurologic deficit, melancholy from maternal drug use. | Three-Four mos| Stepping| Maintain toddler so ft contact strong floor. | Toddler lifts alternate ft as if strolling. | Asymmetry: fracture of extremity, neurologic deficit. | Three-Four mos| Sucking| Place nipple or gloved finger in mouth, rub in opposition to palate. | Toddler begins to suck.
Could also be weak if just lately fed. | Weak or absent: prematurity, neurologic deficit, maternal drug use. | 1 yr| Swallowing| Place fluid on the again of the tongue. | Toddler swallows fluid. Needs to be coordinated with sucking. | Coughing, gagging, choking, cyanosis: tracheoesophageal fistula, esophageal fistula, esophageal atresia, neurologic deficit. | Current all through life. | Tonic neck reflex| Gently flip head to at least one facet whereas toddler is supine. | Toddler extends extremities on facet to which head is turned, with flexion on reverse facet. | Extended interval in place: neurologic deficit. | Could also be weak at delivery; disappears at Four mos|