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LEXINGTON COMMUNITY COLLEGE

Associate Degree Nursing


Nursing 235 Client’s Initials ________
Spring 1999 Date of Birth ________
Gestational Age ________
NEWBORN ASSESSMENT GUIDE

Possible Major Deviations and


Assessment Textbook Information Complications Infant Observation

I. GENERAL MEASUREMENTS

a. Age Term = start of 38th wk. end of 42nd preterm = before end of 37th wk.
week. posterm = after end of 42nd wk.

b. Weight 6.5-7.75 lbs <6 lbs


>9 lbs

c. Length 18-20.5 in
45-52.3 cm

d. Apgar Score 7-10 <7

II. HEAD MEASUREMENT

a. Shape Round symmetrical Microcephaly <32 cm


may have molding--> Hydrocephaly >4 cm from chest
overriding sutures. Cephalohematoma
Slight asymmetry.

b. Size in relation to body 33-35 cm


2 cm> chest circ
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

c. Fontanels size, shape, Sutures, palpable Full bulging, large, depressed


consistency slight Closed sutures
pulsation
1. Anterior Soft
3-4 cm long
2-3 cm wide
diamond shape
2. Posterior 1-2 cm
triangular

III. EYES

a. Color Grayish blue or gray brown iris. Blue Jaundiced sclera.


white sclera.

b. Movement Random, jerky, uneven. Focus Gross nystagmus


momentarily. Follows to midline. Constant Strabimus
Doll’s eye’s > 10 d.

c. Reaction to Light Pupils equal in size, round and Pupils unequal, restricted, dilated,
reactive to light. May turn toward fixed
soft light.

d. Tears Without or occasionally. Discharge

e. Evidence of sight Focuses and follows by 15 min of Does not respond to light, focus or
age. See above, reaction to light. follow.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

f. Eyelids Size and movement symmetric. Does not respond to light, focus, or
Blink reflex. Edema from follow.
prophylaxis. Eyes on a parallel plane.

IV. EARS

a. reaction to noise Startle reflex to loud noise. Attends Absence of reaction.


to sound. By 15 min. of age may
move eyes in direction of sound.
Responds to crooning by relaxation.

b. Position Line drawn through inner and outer Low placement


canthi of eye comes to top notch of
ear (where it connects with scalp.)
Symmetrical.

c. Patency Evidence of hearing. Reaction to


noise.

V. NOSE Midline

a. Mucus Clear Copius drainage

b. Patency Infants obligatory nose breathers. Cyanosis at rest.


Sneezing is common. Flaring or nares.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

c. Reflexes Dependent on state of wakefullness


and hunger.

1. Sucking

2. Swallow

3. Gag See Section XXI. REFLEXES

VI. MOUTH Symmetrical Mouth drawls to one side


Presence of gag and swallowing
Hard & soft palate in tact
Epstein’s Pearls
Clefts

VII. NECK

a. Length Short, thick, surrounded by skin Webbing


folds.

b. Mobility Head held midline. Free movement Rigid.


from side to side. Full flexion and Restricted movement.
extension. Cannot move head past Head held at angle.
shoulder.
Without head control.

VIII. CHEST

a. Size 1-2 cm <head circ. <30 cm


30-33 cm
b. Breast tissue 3-10 mm breast nodule Lack of breast tissue
Nipples prominent
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

c. Characteristic shape Almost circular. Bulging of chest.


Barrel shaped. Retractions.
Bowel sounds in chest.

IX. RESPIRATIONS

a. Rate 30-60/min Tachypnea > 60/min


Bradypnea < 25/min

b. Rhythm Shallow. Labored breathing.


Irregular when infant awake.

c. Breath Sounds No sounds heard without stethoscope. Grunting, rales, rhonchi, wheeze (with
or without stethoscope)

Bronchial. Loud, clear, near. Apnea > 15 sec.

d. Muscular activity involved Simultaneous rise and fall of chest Subcostal and substernal retractions.
and abdomen. Diaphragmatic and Flaring of nares. Chin tug.
abdominal breathing.

X. PULSE

a. Rate 120-160/min. Persistent tachycardia-- > 170


180 with crying Bradycardia-- < 120
100/min. if asleep

b. Rhythm May be irregular for brief periods Persistent irregular rhythm.


especially after crying.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

c. Peripheral circulation Femoral pulses palpable, equal, strong. Weak or absent.


Sluggish peripheral circulation.

XI. ARMS AND HANDS

a. Length Arms equal in length. Anelia, phocomelia


Arms longer than legs.

b. Movements Spontaneous. Limited movements.


Full range of motion. Asymmetry of movements.

c. Muscle tone Generally flexed. Fist often clenched tonicity


with thumb under finger. Asymmetric contour.
Poor tone/floppy.
+ scarf sign.

d. Fingers

1. Number Correct Absence of or additional.


Short.

2. Webbing Without Polydactyl


Syndactyl

e. Position Fists often clenched with thumb under Rigid flexion.


finger. Persistent fists.

XII. ABDOMEN

a. Contour Rounded, protruding Abd. distended.


Scaphoid.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

b. Musculature Not fully developed. Sounds in chest.


Bowel sounds audible 1-2 hours after
birth.

XIII. UMBILICAL CORD

a. Number of vessels at 2 arteries 1 artery


birth 1 vein

b. Appearance Clear, gelatin. Bleeding or oozing.


Odorless. Drying. Drainage or redness.

XIV. GENITAL-URINARY

a. Female Ambiguous genitals

1. Labia Usually edematous

a. Size Covers labia minora Majora widely separated

b. Appearance May have pigment. Minora prominent.


Symmetric in size.

2. Vaginal discharge Absence of vaginal orifice.

a. Color Smegma under labia. Fecal discharge.


May be blood tinged.

b. Type Mucoid/white
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

b. Male Ambiguous genitals

1. Testes in scrotum Palpable each side. Undescended.


Large. Rugge. Cremasteric. Scrotum smooth.

2. Urethral meatus at Correct position. Not at tip of penis.


end of penis Prepuce covers glans. Adherent prepuce.
Not easily retractable.

3. Circumcised Yes or no. Excessive bleeding, swelling or


By day 2 white exudate may cover discharge.
glans penis.

c. Voidings

1. Color Clear, light yellow.

2. Amount Well saturated diapers

3. Frequency By 24 hrs after delivery. At least 3-4


times/day

4. Specific gravity 1.008-1.010

XV. RECTUM

a. Patency Good sphincter tone of anus. Good


wink reflex.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

b. Stools

1. Number Meconium by 24 hrs. after birth. Failure to pass meconium.

2. Color Depends on age of infant and type Abd. distention.


of feeding she is receiving. Diarrhea—curdy, green, large water
3. Consistency ring, forceful.

4. Frequency See your book for specifics.

XVI. HIPS

a. Symmetry Gluteal folds even Congenital hip dysplasia

b. Femur heads Intact


No protrusion.

XVII. BACK

a. Appearance Straight, easily flexed.

b. Turns head from side to side in Yes Limitation of movement.


prone position. Can raise head momentarily. Pigmented nevus with tuft of hair
located at base of spine.
Spina bifida.

XVIII. LEGS AND FEET

a. Appearance May appear to have bowed legs.


Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

1. Warmth Equal Different temps.

b. Length Legs of equal length. Unequal


Shorter than arms.

c. Movement Full ROM Hypermobility.


Lack of leg movement.

d. Alignment Foot in straight line. Club foot.


May appear to turn in but easily
rotated externally.

e. Muscle tone General flexion

f. Toes Feet flat. Well lined over 2/3 of


surface.

1. Number Correct Absent or excessive digits.

2. Webbing Without Syndactyly

g. Position General flexion. Most often see Rigid or floppy posture.


legs drawn up against abd.

XIX. SKIN

a. Color Generally pink. Jaundice.


Acrocyanosis. May see some Cyanosis.
mottling. Pallor or dark red.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

b. Textures Smooth, soft. Flexible.May have Thinner or thicker texture.


dry peeling hands and feet. Fish scale skin.
Without edema.

c. Birthmarks Teleangiectases Hemangiomas


Mongolian spots.
Transient hyperpigmentation of
areolas, genitals.

d. Characteristics

1. Milia Distended sebaceous glands


particularly on nose and cheeks.

2. Lanugo Over shoulder, pinnias, forehead, Absent or excessive.


back.

3. Vernix caseosa White, cheesy, odorless. In creases Absent of excessive. Yellow,


and folds. green or foul odor.

4. Ecchymosis Peteciae over presenting part. Over other areas.


Ecchymosis from forceps.

5. Hair Amount varies. Silky, growth Fine, woolly. Coarse, brittle.


pattern toward face and neck. Unusual growth pattern.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

6. Nails Present, extended beyond fingertips. Absence.

7. Peeling Of hands and feet at about day 3. Generalized cracking and/or


peeling.

XX. TEMPERATURE

a. Normal 97.6-98.6 axillary <97 Ax.


>99 Ax.

b. Temperature regulatory Shivering mechanism undeveloped. Temp not stabilized by 10 hrs


mechanism Brown fat. after birth.

c. Heat Loss From evaporation, conduction, Swings of > 2° F from one


convection, radiation. reading to the next.

XXI. REFLEXES

a. Local

1. Blink Response to light stimulus. Tap on Continued blinking with repeated


forehead, bridge of nose, maxilla when taps.
eyes open—blink first 4-5 times.

2. Pupillary Response to light is equal. Round. Failure to respond. Response


Pupil constricts. unequal.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

3. Doll’s eyes When head is turned, eye movement


lags behind.

4. Rooting Turns head in direction of stimulus, Weak or absent.


opens mouth.

5. Sucking/swallowing Follows rooting. Takes hold, sucks ad Weak or absent. Gagging,


obtains fluids. coughing or vomiting with
swallowing.

6. Gag Safety reflex. Do not try to elicit.

7. Yawn Spontaneous.

8. Grasp Finger curl around examiner’s finger.


Toes turn downward.

9. Babinski Hyperextension of all toes with Absent.


dorsiflexion of big toe when one side
of sole is stroked from heel across
ball of foot to toe.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation

b. Generalized

1. Moro (Startle) Symmetric abduction and extension of


arms.
Finger may fan with forefinger and
thumb forming a C. Arms then adduct
in embracing motion and return to
relaxed flexion.

2. Tonic neck (fencing) When head is turned to one side,


extremities on same side extend and on
opposite side flex.

3. Dance/Walking when held upright with one foot Asymmetry of stepping.


touching a flat surface, will stimulate
walking. Will step alternately.

4. Crawling While on abdomen, will make crawling Absent.


movements with arms or legs.

c. Assess the newborn for:

1. Presence or absence of each


reflex.

2. Strength of each reflex.

3. Infant’s response to your


assessment.
Possible Major Deviations
Assessment Textbook Information and Complications Infant Observation

XXII. CRY

a. Frequency Individual, 15-20 min q. 24 hrs to 2 hrs Unconsolable


q. 24 hrs.

b. Pitch Lusty, strong. Moderate pitch. High pitch.


Weak or absent.

XXIII. PERSONALITY AND BEHAVIOR

a. Response to handling Touch, massaging, warmth--> soothing

b. Reactions to environment Low pitch voice--> relaxation. Unconsolable


Responds with quietness and increased
alertness and cuddling, voice.

c. Parent-infant interaction Turns head and focuses when interested. No focus on person handling.
Coordinates body movement to parent’s
voice and body movement.

d. Eating-Sleeping patterns Variations in interest/ hunger. Usually Lethargy


feeds well within 24 hrs. Wakeful
periods about q. 3-4 hours.