Nursing care of a family w/ newborn

Profile of a Newborn
Newborn /Neonatal period From birth through the first 28 days of life
I. VITAL STATISTICS

Weight

Varies depending on the radical, nutritional, intrauterine and genetic factors

Weight in relation to the gestational age should be plotted to :
o Identify newborns that are at risk because of their small size
o Establish a baseline for future evaluation
Weight in relation w/ height and head circumference should also be plotted to :
o Identify disproportionate measurements in newborns
Normal for all races : 2.5 kg (5.5 lb)
Birth weight usually continues to increase w/ each succeeding child in a family
Small for gestational age
Newborns who have suffered IUGR
Preterm Infants
Infants who are healthy but small only because they were born early
Macrosomic Infants
If a newborn weighs more than 4.7 kg (10 lb)
Weight loss
During the first few days after birth, newborn loses 5% to 10% of birth weight (6 to 10 oz)
75 % to 90 % of a newborn weight is fluid
Newborn is no longer under the influence of salt and fluid-retaining maternal hormones
Diuresis begins to remove a part of the infants high fluid load
Newborn also voids and passes stool
Breastfed newborns have a limited intake until about the 3 rd day of life because of the relatively low caloric content and amt of
colostrums they ingest
Formula-fed newborns have also limited intake this time because of the time needed to establish effective sucking
Weight gain
After the initial loss of weight , newborn has 1 day of stable weight ,then begins to gain weight
Breastfed newborns recaptures weight within 10 days
Formula-fed newborns recaptures weight within 7 days
A newborn begins to gain about 2 lb per month (6 to 8 oz per week) for the first 6 mos. of life

Length

46 cm to 54 cm

Head circumference

Measured w/ a tape measure drawn across the center of the forehead and around the most prominent portion of the posterior
head
34 to 35 cm

Chest circumference

Measured at the level of the nipples

If a large amt of breast tissue or edema of breasts is present, the measurement will not be accurate until the edema has
subsided
About 2 cm less than head circumference
32 cm 33 cm

II. VITAL SIGNS

Temperature

Falls almost immediately to below normal because of heat lost and immature temp regulating mechanisms
Newborn w/ a bacterial infection may run a subnormal temp.
97.6 98.6 F / 36.5-37.5 C

Newborns lose Heat by 4 separate mechanisms:

Convection Flow of heat from newborns body surface to cooler surrounding air
Conduction Transfer of body hear to a cooler solid object in contact w/ the baby
Radiation Transfer of body heat to a cooler solid object not in contact w/ the baby
Evaporation Loss of heat through conversion of a liquid to a vapor
Insulation
An efficient means of conserving heat in adults w/c is not effective in newborns
Newborns have little subcutaneous fat to provide insulation
Shivering
A means of increasing metabolism and thereby providing heat in adults and is rarely seen in newborns
Brown fat
A special tissue found in mature newborns
Helps to conserve or produce body heat by increasing metabolism
Found in the intrascapular region, thorax, and peritoneal area
Mechanical Measures to help conserve heat in newborns
Drying and wrapping newborns and placing them in a warmed cribs
Placing newborns against the mothers skin and then covering the newborn w/ a blanket helps to transfer heat from
mother to the newborn (skin to skin care)
All early care of newborns should be done speedily to avoid exposing the newborn to cool air unnecessarily
Any procedure during a newborn must be uncovered such as resuscitation or circumcision should be done under a radiant
heat source to prevent damaging heat loss

Pulse

Heart rate in utero : 120 to 160 bpm

Immediately after birth : 180 bpm
Within 1 hr after birth : 120 to 140 bpm
During crying : 180 bpm
During sleep : 90 to 110 bpm

Remains slightly irregular because of immaturity of the cardiac regulatory center in the medulla
Transient murmurs may result from the incomplete closure of fetal circulation shunts
Always determined by listening for an apical heartbeat for a full min. rather than assessing a pulse in an extremity
Nurse should be able to palpate brachial and femoral pulses but the radial and temporal pulses are more difficult to
palpate w/ any degree of accuracy
Absence of femoral pulses suggests possible coarctation/narrowing of the aorta , a common cardiovascular abnormality

Respiration

30 to 60 breaths per min.

Respiratory depth, rate and rhythm are likely to be irregular
Can be observed most easily by watching movement of a newborns abdomen, because breathing primarily involves the use
of the diaphragm and abdominal muscles
Coughing and sneezing reflexes are present to clear the airway
Newborns are obligate nose-breathers
Short periods of crying may be beneficial w/c increase the depth of respiration and aid in aerating deep portions of lungs
Long periods of crying can exhaust the cardiovascular system

Periodic respirations
Short periods of apnea (w/o cyanosis) w/c last less than 15 sec. ; normal

Blood Pressure

At birth : 80/46 mm Hg
By the 10th day : 100/50 mm Hg
BP in newborn is somewhat inaccurate , so it is not routinely measured unless a cardiac anomaly is suspected
For an accurate reading, the cuff width used must be no more than 2/3 the length of the upper arm or thigh
Tends to increase w/ crying

III. PHYSIOLOGIC FUNCTION

CARDIOVASCULAR SYSTEM
Drying or clamping of the umbilical
cord and stimulation of cold
receptors

Increased PCO2, decreased PO2, and

increasing acidosis

FIRST BREATH

Decreased pulmonary artery

pressure

Increased PO2
Closure of foramen ovale
pressure in left side greater
than in right side
Closure of ductus
arteriosus

Closure of ductus venosus and umbilical

arteries and vein due to decreased flow

CIRCULATORY EVENTS AT BIRTH

Lungs must oxygenate the blood that was formerly oxygenated by the placenta
When the cord is clamped , a neonate is forced to take in O2 through the lungs
As the lungs inflate for the first time, Pressure decreases in the pulmonary artery (artery leading from
the heart to lungs)
The decrease in pressure of pulmonary artery plays a role in promoting closure of the ductus arteriosus ,a
fetal shunt
As pressure increases in the left side of the heart from increased blood volume, the foramen ovale bet.
the 2 atria closes because of the pressure against the lip of the structure
The remaining fetal circulatory structures no longer receiving blood , the blood within them clots and the
vessels atrophy over the next few weeks

Peripheral circulation of
newborn

Remain sluggish for at least first 24 hrs

It is common to observe cyanosis in the infants feet and hands (acrocyanosis) and for the feet to feel
cold to touch at this time

Blood values

Blood volume : 80 to 110 mL per kg of body weight

Oxygen dissociation curve is shifted to the left i.e., Quantity of O2 bound to hemoglobin and partial
pressure of O2 are greater in newborn blood than in an adults blood
Hemoglobin level : 17 to 18 g/100 mL of blood
Hematocrit : bet. 45 % and 50 %
RBC : About 6 million /mm3
Once proper lung oxygenation has been established , the need for the high RBC count diminishes
Bilirubin is a byproduct of the breakdown of RBC
Indirect bilirubin at birth : 1 to 4 mg/100 mL
WBC count : 15,000 to 30,000 cells/ mm3
High WBC count should not be taken as evidence of infection
Polymorphonuclear cells (neutrophils) account for a large part of the leukocytosis
Lymphocytes become the predominant cell type by the end of 1 st mos.
This leukocytosis is a response to the trauma of birth and is nonpathogenic
Capillary heel-sticks
May reveal a falsely high hematocrit or hemoglobin value because of sluggish peripheral circulation
Before obtaining a blood specimen from a heel, warm the foot by wrapping it in a warm cloth, this
increases circulation and improves the accuracy of this value

Blood Coagulation

Newborns have a prolonged coagulation or prothrombin time because they are born w/ lower than normal
level of vit. K
Vit.K is synthesized through the action of intestinal flora is necessary for the formation of :
o Factor II (prothrombin)
o Factor VII (proconvertin)
o Factor IX (plasma thromboplastin component)
Vit. K (AquaMEPHYTON) is usually administered IM into the lateral anterior thigh because of the
newborns diminished blood coagulation ability

RESPIRATORY SYSTEM

First breath

Requires a tremendous amt. of pressure (40 to 70 cm H2O)

Initiated by :
o Combination of cold receptors
o Lowered partial pressure of O2 (PO2) falls from 80 to 15 mm Hg before a first breath
o Increased partial CO2 pressure (PCO2) rises as high as 70 mm Hg before a first breath
All newborns have some fluid in their lungs from intrauterine life :
o Ease the surface tension on alveolar walls
o Allows alveoli to inflate more easily than if lung wall were dry
2/3 of this fluid is forced out of the lungs by the pressure of vaginal birth
Additional fluid is quickly absorbed by lung blood vessels and lymphatics after the first breath
Once the alveoli have been inflated w/ a first breath , breathing becomes much easier for a baby requiring only about 6 to 8 cm
H2O pressure
Within 10 min. after birth : Newborns have established a good residual volume
By 10 to 12 hrs of age : Vital capacity is established
- Heart in newborn takes up proportionately more space than in adult so the amt. of lung expansion space available is
proportionately limited

A baby born by CS birth

Does not have as much lung fluid expelled at birth as one born vaginally
Have more difficulty establishing effective respirations because excessive fluid blocks air exchange space

A baby who is immature

and whose alveoli collapse
each time they exhale
(lack of pulmonary
surfactant)

Have difficulty establishing effective residual capacity and respirations

If the alveoli do not open

well

Newborns cardiac system becomes compromised because closure of foramen ovale and ductus arteriosus depends on free blood
flow through pulmonary artery and good oxygenation of blood
A newborn who has difficulty establishing respirations at birth should be examined closely in postpartal period for :
o
Cardiac murmur
o
Other indication that he or she still has patent fetal cardiac structures esp. patent ductus arteriosus

GASTROINTESTINAL SYSTEM
- GI tract is usually sterile at birth
- Bacteria may be cultured from the intestinal tract from all babies at 24 hrs of life
- Most of the bacteria enter the tract through :
Newborns mouth from airborne sources
Vaginal secretions at birth
Hospital bedding
Contact at the breast
- Accumulation of bacteria is necessary for digestion and synthesis of vit. K
- Newborns stomach holds about 60 to 90 mL
- Newborn has limited ability to digest fat and starch because pancreatic enzymes, lipase, and amylase remain deficient for the 1 st few mos. of life
- They regurgitates easily because of an immature cardiac sphincter bet. stomach and esophagus
- Immature liver function may lead to lowered glucose and protein serum levels
Dipstick Apt test
- Occasionally newborn has swallowed some maternal blood during birth and either vomits fresh blood immediately after birth or passes a black tarry stool after 2
or more days
- Test used to differentiate maternal blood from fetal blood

STOOLS

Meconium

First stool is usually passed w/in 24 hrs after birth

If stool does not pass w/in 24 hrs , possibility of some factor such as meconium ileus, imperforate anus, or
volvulus should be suspected
A sticky, tarlike, blackish-green, odorless material formed from mucus, vernix, lanugo, hormones and CHO that
accumulated during intrauterine life

Transitional Stool

2nd /3rd day :

o Stool changes in consistency and color , becoming green and loose
4th day :
o Breastfed babies pass 3 or 4 light yellow stools a day
o Formula-fed passes 2 or 3 bright yellow stools a day
Stools of breastfed babies are sweet-smelling because breast milk is high in lactic acid w/c reduces amt. of
putrefactive organisms in the stool

Bright green
stools

On newborn place under phototherapy

Increased bilirubin excretion

Gray stools :

Newborns w/ bile duct obstruction

Bile pigments are not entering the intestinal tract

Blood-flecked
stools :

Anal fissure

Consistent black
or tarry :

Intestinal bleeding

Mucus mixed w/
stool or Stool is
watery and loose

Milk allergy, Lactose intolerance, Some other condition interfering digestion or absorption

URINARY SYSTEM
- Average newborn voids within 24 hrs after birth
- Newborns who do not void within 24 hrs should be examined for the possibility of urethral stenosis or absent kidneys or Ureters
- Possibility of obstruction can be assessed by observing the force of urinary stream in both female and male infants :
Male should void w/ enough force to produce a small projected arc
Females should produce a steady stream, not just continuous dribbling
- Kidneys of newborns do not concentrate urine well making their urine usually light-colored and odorless
- Infant is about 6 wks before much control over reabsorption of fluid in tubules and concentration of urine becomes evident

Single voiding : 15 mL
Specific gravity : 1.008 to 1.010
Urinary output (first 1 2 days) : 30 to 60 mL
Week 1 : 300 mL
First voiding :
o May be pink or dusky because of uric acid crystals that were formed in the bladder in
utero
o A small amt of protein may be normally present until the kidney glomeruli are more fully
mature

IMMUNE SYSTEM
- Newborns are prone to infection because they have difficulty forming antibodies against invading antigens until about 2 mos.
- The inability to form antibodies is the reason that most immunizations against childhood diseases are not given to infants younge r than 2 mos.
- But they have some immunologic protection, because they are born w/ passive antibodies (immunoglobulin G) from their mother that crossed the placenta
- Newborns are routinely administered hepatitis B vaccine during the first 12 hrs after birth to protect against Hepa B
- Little natural immunity is transmitted against herpes simplex
NEUROMUSCULAR SYSTEM
- Mature Newborns demonstrate neuromuscular function by :
Moving extremities
Attempting to control head movement
Exhibiting a strong cry
Demonstrating newborn reflexes
- Because of the immaturity of the nervous system, newborns occasionally makes twitching or flailing movements of extremities in the absence of a stimulus
Limpness
- Total absence of a muscular response to manipulation
- Suggests narcosis, shock, or cerebral injury
Newborn Reflex can be tested w/ consistency by using simple maneuvers :

To protect the eye from an any object coming near it by rapid eyelid closure

Serves to help a newborn find food

If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the
head in that direction
Disappears : 6th week of life ; Newborn eyes focus steadily

Blink Reflex

Rooting Reflex

Sucking Reflex

Helps the newborn find food

When a newborns lips are touched , the baby makes a sucking motion
Disappears : 6 mos.
Diminish immediately if it is never stimulated such as in a newborn w/ a tracheoesophageal
fistula who cannot take in oral fluids

Swallowing Reflex

Food that reaches the posterior portion of the tongue is automatically swallowed

Extrusion Reflex

Newborn extrudes any substance that is placed on the anterior portion of the tongue
Helps prevent swallowing inedible substances
Disappears : 4 mos.

Newborn grasp an object placed in their palm by closing their fingers on it

Disappears : 6 weeks to 3 mos.

Newborns who are held in a vertical position w/ their feet touching a hard surface will take a
few quick, alternating steps
Disappears : 3 mos.

Palmar Grasp
Reflex

Step in-Place
Reflex

Placing Reflex

Plantar Grasp
Reflex

Tonic Neck Reflex

Moro Reflex

Babinski Reflex

Magnet Reflex

Elicited by touching the anterior surface of the lower part of a newborns leg against a hard
surface
Newborn makes a quick lifting motions as if to step onto the table

When an object touches the sole of a newborns foot at the base of the toes , the toes grasp in
the same manner as do the fingers
Disappears : 8 to 9 mos.

a.k.a Boxer or Fencing reflex

When newborns lie on their back , arm and the leg on the side toward w/c the head turns extend
and the opposite arm and leg contract
Does not appear to have a function
Does stimulate eye coordination because the extended arm moves in front of the face
May signify handedness
Disappears : 2nd and 3rd mos.

Most accurate method to elicit this reflex is to hold newborns in a supine position and allow
their heads to drop backward about 1 inch, in response to this .. they abduct and extend their
arms , fingers assume a typical C position
Swing arms into an embrace position and pull up their legs against the abdomen (adduction)
Simulates the action of someone trying to ward off an attacker then covering up to protect
himself
Disappears : 4th or 5th mos.

When the sole of the foot is stroked in an inverted J curve from the heel upward , newborn
fans the toes ( + Babinski sign)
Contrast to adult who flexes the toes
Nervous system development is immature
Disappears : 3 mos.

If pressure is applied to the soles of the feet of a newborn lying in a supine position , he or she
pushes back against the pressure
Tests of spinal cord integrity

Crossed Extension
Reflex

If one leg of a newborn lying supine is extended and the sole of that foot is irritated by being
rubbed w/ a sharp object , infant raises the other leg and extends it as if trying to push away
the hand irritating the first leg

Trunk Incurvation
Reflex

When newborns lie in a prone position and are touched along the paravertebral area by a probing
finger, they flex their trunk and swing their pelvis toward the touch

Landau Reflex

A newborn who is held in a prone position w/ a hand underneath, supporting the trunk should
demonstrate some muscle tone

Deep Tendon
Reflex

Patellar Reflex
Test for spinal nerves L2-L4
Can be elicited by tapping the patellar tendon w/ the tip of the finger
Lower leg moves perceptibly if the infant has an intact reflex
Biceps Reflex
Test for spinal nerves C5 and C6
Elicited by placing the thumb of your left hand on the tendon of the biceps muscle on the inner
surface of the elbow , Tap the thumb as it rests on the tendon
You are more likely to feel the tendon contract than to observe movement

THE SENSES

Hearing

A Fetus is able to hear in utero even before birth

Newborns have difficulty locating sound , calm in response to a soothing voice and startle at
loud noises
They recognize their mothers voice almost immediately as if they have heard it in utero

Vision

Newborns see as soon as they are born

They demonstrate sight at birth by blinking at a strong light (blink reflex)
They cannot follow past the midline of vision, they lose track of objects easily
Pupillary reflex or the ability to contract the pupil is present from birth

Touch

Sense of touch is also well developed at birth

They demonstrate it by quieting at a soothing touch and by sucking and rooting reflexes
They also react to painful stimuli

Taste

Taste buds are developed and functioning even before birth

Smell

Sense of small is present as soon as the nose is clear of lung and amniotic fluid

IV. PHYSIOLOGIC ADJUSTMENT TO EXTRAUTERINE LIFE

PERIODS OF REACTIVITY (Desmond, 1963)
- All newborns move through periods of irregular adjustment in the first 6 hrs of life before their body systems stabilize
- The ability to transition from one period to another is an important indicator of neurologic status

First period of
reactivity

Lasts about half an hour

Baby is alert and exhibits exploring, searching activity, often making sucking
sounds
Heart beat and RR are rapid

Resting period

Heart beat and RR slow

Newborn sleeps for about 90 min.

Second period of
reactivity

Bet. 2 and 6 hrs of life

Baby wakes again, often gagging and choking on mucus that has accumulated in
the mouth
Alert again and responsive and interested in surroundings

Appearance of a Newborn
I. SKIN
Color

Ruddy (reddish)
complexion

Most term newborns have this complexion

Due to
o Increased concentration of RBC in blood vessels
o Decrease in the amt. of subcutaneous fat w/c makes the blood vessels more visible
Fades slightly over the first month

Gray color

Generally indicates infection

Pale/Cyanotic

Infants w/ poor CNS control

Acrocyanosis

Blueness of hands and feet

Normal phenomenon in the first 24 to 48 hrs after birth

Central cyanosis

Cyanosis of the trunk

Indicates decreased oxygenation
May be the result of :
o Temporary respiratory obstruction
o Underlying disease state

Sudden cyanosis
and apnea

Due to mucus obstructing a newborns respiratory tract

Always suction mouth of a newborn before the nose
Suctioning the nose first may trigger a reflex gasp , possibly leading to aspiration if there is mucus in the posterior throat

Hyperbilirubinemia

Leads to jaundice
Result of a breakdown of fetal RBC
Infants skin and sclera of eyes appear yellow
High RBC count built up in utero is destroyed and heme and globin are released
o Globin a protein component that is reused by the body, not a factor in developing jaundice
o Heme is further broken down into iron and protoporphyrin
o Protoporphyrin is further broken down into indirect bilirubin a fat soluble and cannot be excreted by the kidneys in these state, for
removal it is converted by the liver enzyme glucuronyl transferase into direct bilirubin , a water soluble, incorporated into stool and
then excreted in feces

Many newborns have immature liver function that indirect bilirubin cannot be converted to direct form , and therefore remains indirect
As long as the build up of indirect bilirubin remains in the circulatory system, the red coloring of blood cells covers the yellow tint of
bilirubin
When the level of indirect bilirubin has risen to more than 7mg/100 ml , bilirubin permeates the tissue outside the circulatory system
and causes infant to appear jaundiced
Observe infants who are prone to extensive bruising carefully for jaundice because bruising leads to hemorrhage of blood into
subcutaneous tissue or skin
Cephalhematoma a collection of blood under the periosteum of skull bone , can be another cause of jaundice as bruising in these locations
heals and RBC are hemolyzed , additional indirect bilirubin is released
If intestinal obstruction is present and stool cannot be evacuated , intestinal flora may break down bile into its basic components leading
to release of indirect bilirubin into the bloodstream again
Early feeding of newborns promotes intestinal movement and excretion of meconium
Kernicterus
Above normal indirect bilirubin leaves the bloodstream (20 mg/100 mL) can interfere w/ the chemical synthesis of brain cells resulting in
permanent cell damage
Permanent neurologic damage , including cognitive challenge may result
Phototherapy
If bilirubin level rises to more than 10-12 mg/100 mL treatment is usually considered
Exposure of the infant to light to initiate maturation of liver enzymes
Pregnanendiol
A metabolite of progesterone
Found in breastmilk

 Depresses the action of glucuronyl transferase

However, breatfeeding alone rarely causes enough jaundice to warrant therapy

Pallor

May be caused by
o Excessive blood loss when the cord was cut
o Inadequate flow of blood from cord into infant at birth
o Fetal-maternal transfusion
o Low iron stores caused by poor maternal nutrition during pregnancy
o Blood incompatibility in w/c a larger number of RBC were hemolyzed in utero
o Internal bleeding
Infant should be closely observed for signs of blood in stool or vomitus

Harlequin Sign

Because of immature circulation, a newborn who has been lying on his or her side appears red on the dependent side of the body and pale
on the upper side , as if a line had been drawn down the center of the body
A transient phenomenon and of no clinical significance
Fades immediately if infants position is changed or the baby kicks or cries vigorously

Birthmarks
Hemangiomas
- Vascular tumors of skin
- 3 types :

Nevus flammeus

Port-wine stain
Dark red lesion
Typically appear on face, thighs, bridge of the nose
Can be covered by a cosmetic preparation later in life or removed by laser therapy, although
lesions may reappear after treatment
Storks beak marks / telangiectasia
Lighter , pink patches at the nape of the neck
Do not fade
Occur more often in females than in males

Strawberry
Hemangioma

Elevated areas formed by immature capillaries and endothelial cells

May be present after birth or up to 2 weeks after birth
Typically not present in the preterm infant because of the immaturity of the epidermis
Formation is associated w/ high estrogen levels of pregnancy
May continue to enlarge up to 1 yr of age
After first year , they tend to be absorbed and shrink in size
By the time the child is 7 yrs old , 50 % to 75 % of these lesions have disappeared
Application of hydrocortisone ointment may speed the disappearance by interfering w/ the
binding of estrogen to its receptor site

Cavernous
Hemangioma

Dilated vascular spaces

Do not disappear w/ time
Can be removed surgically
Steroids, interferon-alfa-2a or vincristine can be used to reduce size

Mongolian spots
Collection of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or
buttocks , and possibly on arms or legs
Disappear by school age w/o treatment

Vernix caseosa
- A white cream cheese-like substance that serves as a skin lubricant in utero
- Document the color of vernix because it takes on the color of amniotic fluid

yellow vernix

amniotic fluid was yellow from bilirubin

green vernix

meconium was present in amniotic fluid

Lanugo
- Fine, downy hair that covers a newborns shoulders , back, and upper arms and also on forehead and ears
- Post mature infants = less lanugo
Premature infants = more lanugo
- Rubbed away by friction of bedding and clothes against newborns skin
- Disappeared by 2 wks
Desquamation
- Skin peeling
- Within 24 hrs after birth , skin of most newborns has become extremely dry
- Dryness is particularly evident on palms of hands and soles of feet
- Normal and needs no treatment
- Newborns who are postmature and have suffered intrauterine malnutrition may have extremely dry skin , it should be differentiated from normal desquamation
Milia
- All newborn sebaceous glands are immature
- A white papule (plugged or an unopened sebaceous gland) can be found on the cheek or across the bridge of the nose of almost every newborn
- Disappear by 2 to 4 wks as the sebaceous glands mature and drain
Erythema toxicum
- Newborn rash / Flea-bite rash
- Appears in 1st to 4th day of life but may appear up to 2 wks of age
- Begins w/ a papule , increases in severity to become erythema by the 2 nd day and then disappears by the 3rd day
- One of the characteristics of the rash is its lack of pattern
- Occurs sporadically and unpredictably and may last hours rather than days
- Caused by a newborns eosinophils reacting to the environment as the immune system matures
- Requires no treatment
Forceps marks
- Circular or linear contusion matching the rim of the blade of the forceps on the infants cheek
- Disappears in 1 to 2 days along w/ the edema that accompanies it
- Result of normal forceps use
- Does not denote unskilled or too vigorous application of forceps
Skin turgor
- Should feel resilient if the underlying tissue is well hydrated
- If a fold of skin is grasped bet the thumb and fingers, it should feel elastic , when it is released it should fall back
- If severe dehydration is present, skin will not smooth out again but will remain in an elevated ridge
- Poor turgor is seen in newborns who :
> Suffered malnutrition in utero
> Have difficulty sucking at birth
> Have certain metabolic disorders

II. HEAD
Fontanelles
Spaces or openings where the skull bones join

Anterior
fontanelle

Posterior
fontanelle

Located at the junction of 2 parietal bones and 2 fused frontal bones

Diamond shaped
Measures 2 to 3 cm in width ; 3 to 4 cm in length
Can be felt as a soft spot
Should not appear indented (sign of dehydration) or bulging (sign of ICP)
May be bulge if newborn :
o Strains to pass a stool
o Cries vigorously (pulse may additionally be seen)
o Lying supine
Closes at 12 to 18 mos.

Located at the junction of the parietal bones and occipital bone

Triangular shaped
Measures about 1 cm in length
Closes by the end of second month

Sutures
- Separating lines of the skull may override at birth due to extreme pressure exerted on the head during passage through birth canal
- If sagittal suture bet. parietal bones override , the fontanelles are less perceptible than usual
- Overriding subsides in 24 to 48 hrs
- Should never appear widely separated that may suggest ICP because of :
> Abnormal brain formation
> Abnormal accumulation of CSF
> Accumulation of blood from a birth injury (e.g., subdural hemorrhage)
- Fused suture lines are also abnormal , they will prevent the head from expanding w/ brain growth
Molding
- Part of infants head that engaged in cervix usually the vertex molds to fit the cervix contours during labor
- Head will restore to its normal shape within a few days after birth
Caput succedaneum
- Edema of the scalp at the presenting part of the head
- Edema w/c crosses the suture lines is gradually absorbed and disappears at about 3 rd day of life
Cephalohematoma
- Collection of blood bet. the periosteum of a skull bone and the bone itself
- Caused by rupture of periosteal capillary because of birth pressure
- Swelling usually appears 24 hrs after birth
- Discolored because of the presence of coagulated blood
- Confined o an individual bone so the associated swelling stops at the bones suture line
- Often takes weeks to be absorbed
- Condition will subside by itself
- As the blood captured in the space is broken down, a great amt. of indirect bilirubin may be released leading to jaundice
Craniotabes
- Localized softening of the cranial bones
- Caused by pressure of the fetal skull against the mothers pelvic bone in utero
- More common in first born infants because of the lower position of the fetal head in pelvis during last 2 wks of pregnancy in primiparous women

- Skull is so soft that pressure of an examining finger can indent it

- Bone returns to its normal contour after the pressure is removed
- No treatment as the infant takes in calcium in milk
- Would be pathologic in an older child or adult whom it probably would be the result of faulty metabolism or kidney dysfunction
III. EYES
- Newborns usually cry tearlessly because their lacrimal ducts do not fully mature until about 3 mos.
- Irises Gray or blue
Sclera Blue (because of thinness)
- Infants eyes assume their permanent color bet. 3 and 12 mos.
- Should be clear, w/o redness or purulent discharge
- Administration of an antibiotic ointment (e.g., erythromycin) is given at birth to protect against
> Chlamydia infection
> Ophthalmia neonatorum /gonorrheal conjunctivitis

Subconjunctival
hemorrhage

Pressure during birth leading to rupture of conjunctival capillary of eye

Appears as a red spot on the sclera or as a red ring around the cornea
Bleeding is slight , requires no treatment , completely absorbed within 2 to
3 wks

Edema

Often present on the eyelids

Remains for the first 2 or 3 days until newborns kidneys are capable of
evacuating fluid more efficiently

Congenital
glaucoma

Cornea should appear round and proportionate in size

Cornea that appears larger than usual may be the result of this

Coloboma

An irregularly shaped pupil or discolored iris may denote this

Congenital
cataract

Pupil should be dark

A white pupil suggest this

IV. EARS

External ear

Is not as completely formed as it will be eventually

Pinna

Should be strong enough to recoil after bending

Low set ears

Associated w/ chromosomal abnormalities

Level of top part of the external ear should be on a line drawn from the
inner canthus to the outer canthus of eyes

A small tag of
skin

Sometimes found just in front of an ear

Isolated findings and of no consequence
Can be removed by ligation immediately or when the child is 1 week old

Preauricular
dermal sinus

May be present directly in front of the ear

Inspect in front of newborns ears for pinpoint-size openings that reveal
these sinuses
Usually small and can be removed surgically

Tympanic
membrane

Visualization is difficult and usually is not attempted because amniotic fluid

and flecks of vernix still fill the canal , oblitering the drum and its
accompanying landmarks

V. NOSE
Choanal
atresia

Blockage at the rear of the nose

Test is by closing the newborns mouth and compressing one naris at a time w/
your fingers
Not any discomfort or distress while breathing this way

Nasal flaring

Indication of respiratory distress

VI. MOUTH

Cranial nerve
injury

- Mouth should open evenly when he or she cries

- If one side of mouth moves more than the other

Epsteins pearls

- Small ,round , glistening , wellcircumscribed cysts that are present on the palate
- Result of extra calcium that was deposited in utero
- Insignificant and will disappear within 1 week

Thrush

- Candida infection
- Usually appears on the tongue and side of the cheeks as white or gray patches
- Needs therapy with an antifungal drug

Mucus

- All newborns have some mucus in the mouth

- Increased amt in newborns who delivered by CS birth
- If a newborn is placed on the side, mucus drains from the mouth and results no
distress

Tracheoesophageal
fistula

- Inadequately formed esophagus

- If mouth is filled w/ so much mucus that a neonate seems to be blowing bubbles
- Must be confirmed before the newborn is fed otherwise formula can be
aspirated into lungs

Benign inclusion
cysts

-Small , white epithelial pearls may be present on the gum margins

- No therapy is needed

Natal teeth

- Teeth of the newborn

- Must be evaluated for stability
- If loose, should be extracted to prevent possible aspiration during feeding

VII. NECK
- Short and often chubby w/ creased skin folds
- Head should rotate freely on it
- Not strong enough to support the total weight of the head
- Should make some effort to control and steady the head as they reach in some position
- Trachea may be prominent on the front of the neck
- Thymus gland may be enlarged because of rapid growth of glandular tissue ; will triple in size by 3 yrs of age ; remains in that size of 3 yrs of age until the child is
about 10 yrs old and then shrinks

Congenital
torticolis

Rigidity of the neck

Caused by injury to the sternocleidomastoid muscle during
birth

Meningitis

In newborns whose membranes were ruptured more than 24

hrs before birth
Nuchal rigidity suggests this

VIII. CHEST
- Chest measurement exceeds that of the head at about 2 yrs of age
- Should appear symmetric side to side
- Clavicles should be straight

Crepitus

Actual separation on one or the other clavicle may indicate a fracture occurred during birth
Calcium is now being deposited at that point
As the area heals, it may be possible to palpate a lump on the clavicle caused by temporary
calcium overgrowth

Supernumerary
nipple

Found below and in line w/ the normal nipple

May be present

Engorgement of
the breasts

In both female and male infants

Occasionally, breasts of the newborn secrete a thin, watery fluid termed witchs milk
Develops in utero as a result of the influence of the mothers hormones
As soon as the hormones are cleared from the system at about 1 week, it subsides
Fluid should never be expressed , manipulation could introduce bacteria and lead to mastitis

Retraction

Drawing in of the chest wall with inspiration

Should not be present
Infant is using such a strong force to pull air into respiratory tract by pulling the anterior
chest muscle

Rhonchi

Harsh, innocent sound of air passing over mucus

Because a newborns alveoli open slowly over the first 24 to 48 hrs and baby invariably has
mucus in the back of the throat , lung sound often reveals this sound

Grunting

Abnormal sound suggesting respiratory distress syndrome

Stridor or
Immature
tracheal
development

There is a high , crowing sound on inspiration w/c suggests this two

IX. ABDOMEN

Normal abdomen
appearance

Slightly protuberant

Scaphoid or
Sunken
appearance

May indicate missing abdominal contents or diaphragmatic hernia (bowel positioned in the
chest instead of the abdomen)

Bowel sounds

Should be present within 1 hr after birth

Edge of the liver

Usually palpable 1 to 2 cm below the right costal margin

Edge of the
spleen

May be palpable 1 to 2 cm below the left costal margin

Tenderness

Difficult to determine
If it is extreme , palpation will cause infant to cry , thrash about or tense the abdominal
muscles to protect the abdomen

Umbilical cord

Stump of the umbilical cord appears as white, gelatinous structure marked w/ blue and red
streaks of umbilical vein and arteries (AVA)
Single artery is associated w/ a congenital heart or renal abnormality
Inspect the cord clamp to be certain it is secure
o After the first hr of life, the cord begins to dry and shrink and turns brown
o By 2nd or 3rd day, it has turned black
o By 6th to 10th day , it breaks free
o There should be no bleeding at the cord site
o Base of the cord should be dry
Bleeding suggest
o Cord clamp has become loosened
o Cord has been tugged loose by friction of bedclothes
Moist or Odorous cord suggest
o Infection
o Patent urachus (a canal that connects the bladder and the umbilicus) w/c will drain urine
at the cord site until it is surgically repaired
Inspect the base of the cord to be certain no abdominal wall defect (e.g., umbilical hernia) is
present

Kidneys

Attempt to verify presence of kidneys by deep palpation of the right and left abdomen w/in
first few hrs after birth (after this time, intestines will fill w/ air making palpation more
difficult)
o Right kidney can usually be palpated readily because it is located lower than left
o Left kidney is more difficult to locate, intestine is bulkier on the left side and kidney is
higher in the retroperitoneal space
o Newborn kidneys are about the size of a walnut
An enlarged kidney suggests
o Polycystic kidney
o Pooling of urine from a urethral obstruction

Abdominal reflex
(Test for spinal
nerves T8-T10)

Stroking each quadrant of the abdomen will cause umbilicus to move or wink in that direction
May not be demonstrable in newborns until the 10th day of life

X. ANOGENITAL AREA
Anus

Inspection

Be certain it is :
o Present
o Patent
o Not covered by a membrane

Test for anal

patency

By gently inserting the tip of your gloved and lubricated little finger
Note the time after birth at w/c infant first passes meconium

Imperforate anus
or meconium ileus

If newborn does not pass meconium in the first 24 hrs

Male genitalia

Scrotum

Edematous and has rugae

May be deeply pigmented in dark-skinned newborns

Testes

Both should be present in scrotum

Press the nondominant hand against the inguinal ring before palpating so they do not slip
upward and out of the scrotal sac as you palpate
Elicit a cremasteric reflex (Test for spinal nerves T8-T10)
o By stroking the internal side of the thigh
o As the skin stroked, testis on that side moves perceptibly upward
o Response may be absent in newborns who are younger than 10 days

Cryptorchidism

One or both testicles are not present

Could be caused by :
o Agenesis (absence of organ)
o Ectopic testes (testes cannot enter the scrotum because the opening to the scrotal
sac is closed)
o Undescended testes (vas deferens or artery is too short to allow testes to descend)
Newborns w/ agenesis of testes usually referred for investigation of kidney anomalies
because testes arise from the same germ tissue as the kidneys

Penis

Small , app. 2 cm long

Inspect the tip to see that the urethral opening is at the tip of the glans
Circumcision should not be done if hypospadias and epispadias is present

Epispadias

Tip is on the dorsal (posterior) surface

Hypospadias

Tip is on the ventral (anterior) surface

Female genitalia

Vulva

May be Swollen because of the effect of maternal hormones

Pseudomenstruation

Mucus vaginal secretion w/c is sometimes blood-tinged

Caused by action of maternal hormones
Diasappears as soon as infants system has cleared the hormones
Should not be mistaken for infection

XI. BACK
- Spine of a newborn appears flat in the lumbar and sacral area
- Curves seen in an adult appear only after a child is able to sit and walk
- Should be no pinpoint, dimpling or sinus tract in skin w/c would suggests a dermal sinus or spina bifida
- Newborn normally assumes position maintained in utero w/ the back rounded and arms and legs flexed on the abdomen and chest

XII. EXTREMITIES

Upper extremities

Arms and legs should move symmetrically

An arm that that hangs limp and unmoving suggests : (Possible birth injury)
o Injury to clavicle
o Injury to the brachial or cervical plexus
o Fracture of a long bone
Assess for :
o Webbing (Syndactyly)
o Extra fingers or toes (Polydactyly)
o Unusual spacing of the toes (often present in certain chromosomal disorders but also a
normal findings in some families )
Test the upper extremities for muscle tone
o By unflexing the arms for app. 5 sec.
o If tone is good, an arm shoud return immediately to its flexed position after being
released
Note length of the arms
o Fingertips should reach the proximal thigh
Inspect palm for simian crease w/c is commonly associated w/ Down syndrome

Achondroplastic dwarfism
Unusually short arms may signify this
Hips
Can be Flexed and Abducted to such an extent (180 degrees) that the knees touch or nearly
touch the surface of the bed
Hip subluxation
If hip joints seem to lock short of distance (160-170 degrees)
May be bilateral but is usually unilateral
Further test for this can be elicited by holding the infants leg w/ fingers on the greater and
lesser trochanter and then abducting the hip :
o Ortolanis sign if subluxation is present, a clunk of the femur head striking the shallow
acetabulum can be heard
o Barlows sign if hip can be felt to actually slip in the socket
When lying on the abdomen
Newborns are capable of bringing their arms and legs underneath them and raising their
stomach off the bed high enough for a hand to be slipped underneath , this ability helps to
prevent pressure or rubbing at the cord site
Preterm newborn does not have this ability

Lower extremities

Normally legs are bowed as well as short

Sole of foot appears flat because of an extra pad of fat in the longitudinal arch
Foot of a term newborn has many crisscrossed lines on the sole , less lines indicate immaturity
Feet of many newborn turn in (varus deviation) because of their former intrauterine position ;
needs no correction if feet can be brought into midline position by easy manipulation

Talipes deformity (clubfoot)

If foot does not align / not turn to a definite midline position
Check for Ankle clonus
By supporting the lower leg in one hand and dorsiflexing the foot sharply 2 or 3 times by
pressure on the sole of the foot w/ the other hand
After the dorsiflexion
o 1 or 2 continued movements are normal
o Rapid alternating contraction and relaxation (clonus) are abnormal
Abnormal response suggests neurologic involvement