Assessment of the Normal Newborn Ch. 20

General Assessment

If major abnormalities are present at birth, the nurse must maintain a calm quiet demeanor to avoid frightening the parents The physician should be alerted quietly and will explain the condition and possible plan of treatment

Reflexes

STUDY P. 393

Face

The face is examined for symmetry, positioning of the facial features, movement, and expression A transient asymmetry from intrauterine pressure may occur, lasting a few weeks or months Drooping of the mouth appears as a one-sided cry and may be caused by facial nerve trauma Irregularities of the facial features should be reported

History

The maternal age, health problems, and any complications during the pregnancy or birth may affect the neonate's adaption at birth Preterm infants may not produce adequate amounts of surfactant, and atelectasis may occur bc the alveoli do not remain open.

Further Assessments

When an infants gest age or measurements fall outside the expected range, the nurse monitors for complications. Specific complications are common to rpeterm, postterm, SGA, and LGA infants. For example, pregnancy complications may cause a poorly functioning placenta and an SGA infant. LGA infants are also prone to complcations.

Early Focused Assessments

As soon as the infant is born, the nurse performs assessments that are most immediately crucial to determining the neonate's health status These include: Cardiorespiratory status, thermoregulation, and the presence of anomalies When the infant is stable and oxygenating well, a more thorough assessment can be performed Nurse should wear gloves while handling newborn until they are bathed and all blood is removed

Capillary Refill

Checked by depressing the skin over the chest, abdomen, or an extremity until the area blanches color should return within less than 3-4 seconds

Plantar surface

Plantar creases begin to appear at 28-32 weeks of gestation and cover the entire foot by term Although the creases are only red lines near the toes at first, they gradually spread down toward the heel and become deeper The plantar creases must be assessed during the early hours after birth because the creases appear more prominent as the infants skin begins to dry For the very preterm infant, the length of the foot is measured to help determine gest age

Documentation

Size, color, elevation, and texture of each mark are described When in doubt about the name of a mark, a description is sufficient A nevus simplex (stork bite) might be described as a flat, pink area 1 x 2 in size over nape of the neck that blanches with pressure

Integumentary System: Skin p. 399

The newborns skin is fragile and shows marks easily, esp in infants with fair coloring Bc the skin is so sensitive, reddened areas and rashes may develop during the early days of life The nurse must examine every inch of the skin surface carefully during the initial assessment and at the beginning of each shift Marks should be documented and explained to parents who may be worried

Vertebral Column

The nurse palpates the entire length of the newborns vertebral column to discover any defects in the vertebrae An indentation is a sign of spina bifida occulta (failure of vertabrae to close). The defect is not obvious on visual inspection because it is covered with skin, but sometimes a tuft of hair grows over the area Other more obvious neural tube defects include meningocele (protrusion of spinal fluid and meninges) or myelomeningocele (protrusion of spinal fluid, meninges, and the spinal cord) through the defect in the vertebrae They appear as a sack on the back and may be covered by skin or only meninges The tissue should covered with moist, sterile, saline dressings immediately after birth A pilonidal dimple may be present at the base of the spine It should be examined for a sinus and the depth noted

Parent's Response

The parent's growing ability to respond to the infants behavioral cues should be noted The nurse can point out the infants behavioral changes to facilitate bonding and help the parents learn to interpret the infants cues. The methods that the parents use to meet the infant's needs during different behavior states also are noted.

Sense of Smell and Taste

The sense of smell is demonstrated when infants recognize breast pads soaked with their mother's milk and differentiate them from pads soaked in water Their ability to distinguish taste is shown by their preference for sweet liquids and aversion to sour or bitter tastes.

Square Window

The square window sign is elicited by flexing the hand at the wrist until the palm is as flat against the forearm as possible with gentle pressure The angle between the palm and forearm is measured If the palm bends only 90 degrees, the score is 0 The gest age of the infant is probably 32 weeks or less The more mature the neonate, the smaller the angle until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy.

Cord

The umbilical cord should contain 3 vessels The 2 arteries are small and may stand up at the cut end The single vein is larger than the arteries and resembles a slit because its walls are more easily compressed If only one artery is present, the infant is carefully assessed for other anomalies A two-vessel cord may be an isolated abnormality or assoc with chromosomal and renal defects The amount of Wharton's jelly in the cord is noted If the cord appears thin, the infant may have been poorly nourished in utero A yellow-brown or green tinge to the cord indicates that meconium was released at some time before birth, perhaps as a result of fetal compromise No redness or discharge from the cord should be present.

Popliteal Angle

To measure the popliteal angle, the newborns lower leg is folded against the thigh, with the thigh on the abdomen With the thigh still flexed on the abdomen, the lower leg is straightened just until resistance is met Continued pressure causes the infant to further extend the leg and results in an inaccurate score The angle at the popliteal space when resistance is first felt is scored on a scale of 0-5 The preterm infant extends the leg farther than the full-term infant The leg may extend with little resistance if the infant was in a frank breech postion

Abdomen

Abdomen should be soft, rounded, and should protrude slightly, but should not be distended Stomach may be distended by mucus, blood, and amniotic fluid swallowed during birth An abdomen so distended that the skin is stretched and shiny may indicate obstruction If abd is distended, the nurse should measure the abdominal circumference periodically to note changes Loops of bowel should not be visible through the abdominal wall. Visible loops could indicate that air and meconium are not passing though the intestines normally A sunken or scaphoid appearance of the abd occurs in diaphragmatic hernia, in which intestines are located in the chest cavity instead of the abdomen This condition interferes with the development of the lungs, resulting in resp difficulty at birth The nurse listens over the abd for bowel sound, which usually appear 15 min after birth Bowel sounds heard in the chest may indicate diaphragmatic hernia An umbilical hernia occurs when the intestinal muscles fail to close around the umbilicus, allowing the intestines to protrude through the weak area More common in low birth weight, african american, male By the time the infant is walking well, the muscles are usually strong enough that the hernia no longer is present. Some umbilical hernias require surgical resection Palpating the abd is easiest when the infant is relaxed and quiet The abd should feel soft bc the muscles are not yet well-developed. Masses may indicate tumors of the kidneys Palpation of the liver and kidneys is usually not routine but is performed by physician The liver is normally 1-2 cm below the right costal margin If liver seems large it should be reported to physician bc it may be a sign of congestive heart failure or congenital infection

Caput Succedaneum

An area of localized edema that appears over the vertex of the newborns head as a result of pressure against the mothers cervix during labor This pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. It resolves quickly and generally disappears within 12-48 hours Caput also may occur when a vacuum extractor is used to assist birth When a vacuum is used, the caput corresponds to the area where the extractor was placed on the skill. The amount of edema and presence of bruising are assessed.

Lanugo

Appears at 20 weeks gestation and increases in amount until 28 weeks when it begins to disappear Most is shed by 32-36 weeks A small amount may remain over the upper back and shoulders, on the ears, or on the sides of the forehead The infant receives a score based on the amount of lanugo present on the back

Scoring

As each part of gestational age assessment is performed, the infants response is matched with the diagrams and descriptions on the assessment tool. The total score is compared with the corresponding gestational age *It is important to understand that one or 2 characteristics alone are not enough to assign a gestational age It is the total score of all assessed characteristics that determines gestational age.!* A difference of 2.5 points is necessary to change the gest age by 1 week Therefore, slight differences in the scores of different examiners are not likely to cause significant differences in the outcome of the examination

Physical Characteristics: Skin

Assessed for color, visibility of veins, peeling, and cracking The very preterm infants skin is translucent bc it is thin and has little subq fat beneath surface Skin is red, sticky, and fragile, with easily visible veins in preterm In the mature newborn, the skin is thicker and the color is paler. Few veins are visible, usually over the chest and abdomen At term, vernix is present only in the creases. The full-term infant exhibit some peeling and cracking of the skin, esp around areas with creases, such as the ankles and feet The postmature infant has deeply cracked skin that appears as dry and think as leather Peeling becomes even more apparent during the hours after birth as the skin loses moisture

Genitalia

Assessed for size, maturation, and presence of any abnormalities Female: In full-term infant, the labia majoria should be large and completely cover the clitoris and labia minora. The labia may be darker than surrounding skin, a normal response to exposure to the mother's hormones before birth. Edema of the labia and white mucus vaginal discharge are normal S small amount of vaginal bleeding, known as pseudomenstruation, may occur from the sudden withdrawal of the mothers hormones at birth Hymenal (vaginal) tags are small peices of tissue at the vaginal orifice These are normal and disappear in a few weeks. The urinary meatus and vagina should be present Male: The scrotum should be pendulous at term and may be dark brown from the maternal hormones Pressure during breech delivery may cause it to be edematous Rugae are deep and cover the entire scrotum in the full-term infant Enlargement of one or both sides of the scrotum may result from a hydrocele. This collection of fluid around the testes may make palpating the testes difficult Placing a flashlight against the sac may outline the testes Parents should be told that hydroceles are not painful and often reabsorb within 1 year. Some require curgery Palpation of the scrotum determines whether the testes have descended. Testes feel like small, round, movable objects that slip between the fingers/ If the testes are not present in the scrotal sac, they may be felt in the inguinal canal. An empty scrotal sac appears smaller than ones with testes Undescended testes (cryptorchidism) occurs on one or both sides If testes do not descend in 12 months, surgery is performed to preserve fertility The meatus should be at the tip of the glans penis It may be abnormally located on the underside of the penis (hypospadias), on the upper side (epispadias), or on the perineum The prepuce or foreskin of the penis covers the glans and is adherent to it Attempts to retract it in the newborn are unnecessary and can cause injury Abnormal placement of the meatus may not be visible because it is covered by the prepuce, but often the prepuce in these infants is incompletely formed Hypospadias may be accompanied by chordee, a condition in which fibrotic tissue causes the penis to curve downward. These conditions are later corrected by surgery *If the meatus is abnormally positioned, they need an explanation of the condition and why the infant should NOT BE CIRCUMCISED. The foreskin may be needed for later plastic surgery to repair the defect*

Stools

Assessed for type, color, and consistency By the 3-4th day, stools reflect the type of feeding the infant receives A "water-ring" should never be present around the solid part of any stool A water ring is a wet, stained area on the diaper where watery stool has been absorbed There may be an area of more solid stool in addition, or all stool may have soaked into the diaper A water ring indicates diarrhea and may be caused by formula intolerance or infection The first stool should be passed within 12-48 hours after birth The nurse should be aware of whether any stools have been passed since birth, and if so, when the infant;s last stool occurred If there is a question about whether the infant has had a stool, the nurse must investigate further Feeding may cause the infant to pass a stool Although rectal temps are not recommended, they physician may gently insert a thermometer into the rectum to determine patency and stimulate stool passage

Assessment of Behavior

Assessment of the infants behavior helps determine intactness of the CNS and provides info about the ability to respond to caretaking activities Bc behavior differs at various times after birth, the nurse should be aware of the periods of reactivity and the 6 different states of behavior so that nursing care can be adapted appropriately

Assessment of Cardiorespiratory Status

Assessments of respiratory and cardiocascular status are performed together bc transitional changes take place simultaneously in both systems Problems in one are likely to cause problems in the other

Heart Sounds

Auscultated for rate, rhythm, and the presence of murmurs or abnormal sounds The nurse should count the apical pulse for a full minute for accuracy and listen for abnormalities Rate should be 120-160 bpm May elevate to 180 when infants are crying or drop as low as 100 bpm when they are in deep sleep If no problems are present at birth, the HR should be recorded at least once every 30 minutes until the infant has been stable for 2 hours after birth Once stable, the HR is checked once q 8-12 hours Position: The apex of the heart is located at the point of maximum impulse, where the pulse is most easily felt and the sound is the loudest *This is at the third or fourth intercostal space, lateral to the midclavicular line* Conditions that affect the position of the heart include pneumothorax and dextrocardia Rhythm and Murmurs: The rhythm of the heart should be regular, and the first and second sounds should be heard clearly Abnormalities in rhythm and sounds such as murmurs should be noted Murmurs are sounds of abnormal blood flow through the heart and may indicate openings in the septum of the heart or problems with blood flow through the valves They occur in approx 10% of newborns Most murmurs in newborn are temporary and result from incomplete transition from fetal to neonatal circulation. A murmur is common until the ductus arteriosus is functionally closed. Although it may be a normal or functional murmur, any abnormal sounds of the heart are investigated because they may be signs of cardiac defects Pulse oimetry screening for cardiac defects is often performed before discharge

Cephalhematoma

Bleeding between the periosteum and the skull, is the result of pressure during birth Occurs on one or both sides of the head, usually over the parietal bones The swelling may not be present at birth but may develop within the first 24-48 hours The area is carefully palpated to determine whether the swelling crosses suture lines. A cephalhematoma has clear edges that end at the suture lines It does not cross the suture lines, unlike a caput, because the bleeding is held between the bone and its covering, the periosteum A cephalhematoma reabsorbs slowly and may take 2 to 3 months to completely resolve Bc of the breakdown of the RBCs within the hematoma, affected infants are at greater risk for jaundice Bruising also increases risk of jaundice Both caput and cephalhematoma may be frightening to parents. They need reassurance that the conditions are not harmful to the infant Even if parents do not ask, they need information about the causes and length of time required for the areas to resolve

Skin

Cafe-au-lait Spots: Permanent, light-brown areas that may occur anywhere on the body Although they are harmless, the number and size are important. 6 or more spots or spots larger than 0.5 cm are assoc with neurofibromatosis, a genetic condition of neural tissue. Marks from Delivery: The nurse inspects the infant for marks that may have occurred from injury or pressure during labor or birth Bruises may appear on any part of the body where pressure occurred during birth. Bruising or petechiae of the face may be present if the cord was wrapped tightly around the neck during birth (nuchal cord). Bruising on the head may result from use of a vacuum extractor. Petechiae, pinpoint bruises that resemble a rash, may appear on the back, face, and groin. They result from increased intravascular pressure during the birth process. *Widespread or continued formation of petechiae may indicate infection or a low platelet count* A small puncture mark is present on the newborns head if a fetal monitor scalp electrode was attached. The area should scab and heal normally but is observed for signs of infection. Forceps marks occur over the cheeks and ears where the instruments were applied. Their size, color, and location are carefully documented. Asymmetry or lack of movement of the face may indicate injury of the facial nerve. Other Skin Assessments: The nurse records other aspects of the skin that may indicate abnormalities. Localized edema may be caused by trauma from birth. Generalized edema shows a more serious condition such as heart failure. Peeling of the skin is normal in full-term newborns. Excessive amounts of peeling may indicate a postterm infant.

Airway

During birth, some fetal lung fluid is forced into the upper airway and expelled Excessive fluid and mucus in the infants resp passages may cause resp difficulty for several hours after birth Resp Rate: Assess respirations at least every 30 min until the infant has been stable for 2 hours after birth *The normal resp rate is 30-60 breaths/min* Average is 40-49 breaths/min May breathe faster immediately after birth, when crying, during the first and second periods of reactivity Resps should not be labored, and the chest movements should be symmetric Bc the pattern and depth of resp are irregular, they must be counted for a full minute for accuracy Counting rapid, shallow, irreg resps of a newborn can be a challenge. Differentiating between the resps and other movements while observing the infants chest may be difficult Observation, auscultation, or palpation alone or in combination may be used to obtain an accurate resp rate The nurse observes for periodic breathing, pauses in breathing lasting 5-10 seconds without other changes followed by rapid resps for 10-15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants Apnea is a pulse in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, or decreased muscle tone *Apnea is abnormal and requires prompt intervention* Breath Sounds: The anterior and posterior lung fields are auscultated for breath sounds, which should be present equally throughout. Breath sounds should be clear over most areas Hearing sounds of moisture (crackles) in the lungs during the first hour or two after birth is not unusual because fetal lung fluid has not been completely absorbed Infants birn by c-section not preceded by labor do not experience the changes that occur in the lungs during labor and birth and are more likely to have coarse breath sounds for a short time Wheezes, crackles, rhonchi, or stridor that persists should be reported Abnormal and diminished sounds always should be reported to the primary care provider if they continue They may indicate a pneumothorax Bowel sounds in the chest may be a sign of diaphragmatic hernia

Periods of Reactivity

During the first and second periods of reactivity, newborns may have elevated pulse and RR, low temp, and excessive resp secretions Careful observation is important at this time but can only be done unobtrusively so that parents can continue to enjoy the newborn During the time between the first and second periods of reactivity, newborns cannot be awakened easily and are not interested in feeding.

Assessment of Gestational Age

Exam of newborns physical and neurologic characteristics to determine the number of weeks from conception to birth. Its important bc neonates born before or after term and those whose size is not appropriate for gestational age are at increased risk for complications. Although gest age may be calculated from the mothers last period and by ultrasonography during the pregnancy, the date of the last period is not always accurate, and ultra not always performed. Because the times of development for various fetal characteristics are known, the presence or absence of these characteristics can help estimate gest age The estimated age then can be compared with the newborns weight, length, and head circumference to determine whether the neonate is large, appropriate (average), or small in size for gest age

Hips

Examined for signs of developmental dysplasia In this condition, instability of the hip joint occurs and the head of the femur can be moved in and out of the acetabulum Partial dislocation and inadequate development of the acetabulum may occur Identifying a hip problem early is important to prevent permanent damage to the joint Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period Both legs should abduct equally in normal infants Abducting the affected hip may be difficult A hip click may be felt or heart but is usually normal and is different from the "clunk" of hip dysplasia when the femoral head moves in the hip socket The infant's knees should be bent with the feet flat on the bed to compare the height of the knees If the hip is dislocated, the knee on the affected side is lower The legs are extended with the infant in a prone position to determine whether they are equal in length and if the thigh and gluteal creases are symmetric If the hip is dislocated, the leg on the affected side is shorter and the creases are asymmetric Bc the hip may be unstable but not yet dislocated, these signs are not usually present at birth Treatment of developmental dysplasia of the hip involves immobilizing the leg in a flexed, abducted position, usually with a harness Early identification and treatment are essential to provide the best results in correcting the problem Treatment may involve casting or surgery if the condition is not discovered early

Arm Recoil

Full-term infants resist extension of the arms In testing for arm recoil, the nurse holds the neonates arms fully flexed at the elbows for 5 seconds, then pulls the hands straight down to the sides The hands are quickly released and the degree of flexion is measured as the arms return to their normally flexed position Preterm infants may move the arms slowly or not at all and receive a score of 0 Somewhat older infants have a sluggish recoil, with only partial return to flexion If the arms move briskly to an angle of less than 90 degrees at the elbows, the score is 4

Blood Glucose

Hypoglycemia can cause brain damage Risk Factors: Premature Postmature Late preterm IUGR LGA or SGA Asphyxia Problems at birth Cold Stress Maternal Diabetes Maternal intake of Terbutaline Observing for signs of hypoglycemia is necessary throughout routine assessment and care Early signs include jitteriness and other CNS and signs of respiratory difficulty, a decrease in temperature, and poor feeding. Some infants with hypoglycemia show no signs at all Screening for glucose is not necessary for normal term infants Those in risk categories or showing early signs should be screened *Normal blood glucose for the term infant during the first day of life is 40-60 mg/dL and 50-90 mg/dL thereafter* Bc capillary blood is used in screening tests, these tests are less accurate than lab tests using venous blood. Therefore, a lab analysis should be used to verify readings of 40-45 or below Avoiding injuries to the infants foot is important when taking blood from the heel If the lancet goes into the calcaneous bone, osteomyelitis may result Commercial devices for heel puncture are designed to puncture the heel to the proper depth They are available fo full-term and preterm infants The site chosen must avoid injury to major nerves and arteries in the area Other complications include cellulitis, abscess, scarring, bruising, and pain. Infants are often fed if the reading is between 40-45 or less to prevent a further decrease in glucose, esp if the infant shows signs of hypoglycemia Tje blood glucose is rechecked 30-60 minutes after the feedings until the results are acceptable Infants who are in risk categories are usually monitored for at least 24 hours after birth

Genitals

In the female infant, the relationship in size of the clitoris, labia minora, and labia majora is noted In the preterm infant, the labia majora are small and separated, and the clitoris and labia minoria are large by comparison As the infant nears term, the labia majora enlarge until the clitoris and labia minora are completely covered Bc the size of the labia majora is affected by the amount of fat deposited, the infant who is malnourished in utero may have genitalia with an immature appearance In the male infant, the location of the testes and the ruage on the scrotum are assessed The testes originate in the abdominal cavity and begin to descend at 28 weeks of gestation By 37 weeks of gestation, they are located high in the scrotal sac, and they are generally completely descended by term Rugae cover the surface of the scrotum by 40 weeks of gestation Once the testes are completely down into the scrotum, the scrotum appears large and pendulous.

Initial Feeding

Initial feeding is an opportunity to further assess the newborn If mother is breastfeeding, she should begin in the first hour after the birth The nurse can observe the infant's response unobtrusively while assisting the mother to position the infant To decrease regurgitation from overdistention of the stomach, an initial formula feeding should be no more than 1 oz The nurse evaluates the infants ability to suck, swallow, and breathe in a coordinated manner. Although the fetus sucks and swallows in utero, these acts may not have been performed together The addition of breathing to sucking and swallowing is a new experience Some newborns choke or gag during the first feeding Others become dusky or cyanotic bc they become apneic while feeding In either case the nurse should stop the feeding immediately, suction if necessary, and stimulate the infant to cry by rubbing the back Most full-term infants learn to coordinate sucking, swallowing, and breathing very quickly Choking, coughing, cyanosis, or excessive oral secretions may indicate closure of the esophagus (esophageal atresia) or a connection between the trachea and esophagus (tracheoesophageal fistula) Neonates who continue to have difficulty with cyanosis during feedings may have a cardiac anomaly Further assessment and referral are necessary

Mouth

Inspected visually and by palpation Some infants are born with precocious teeth, usually lower incisors If the teeth are loose, the physician usually removes them to prevent aspiration Epstein's pearls may be present on the hard palate or gums These small, white, hard, inclusion cycsts are accumulations of epithelial cells and disappear without treatment in a few weeks They are a form of milia The nurse examines the tongue for size and movement A large, protruding tongue is present in hypothyroidism and some chromosomal disorders such as trisomy 21 Paralysis of the facial nerve affects the movement of the tongue and causes unilateral drooping of the mouth noticeable during crying or sucking. The tongue may appear to be tongue-tied bc of the short frenulum, but this is normal and usually has no effect on the infants ability to feed. In a true tongue-tie, there is limited tongue movement Clipping of the frenulum seldom is practiced because of the potential for infection. Although candidiasis (thrush) is not apparent in the mouth immediately after birth, it may appear 1 or 2 days later The lesions resemble milk curds on the tongue and cheeks that bleed if attempts are made to wpipe them away, Newborns become infected with Candida Albicans during the passage through the birth canal if the mother has a candidal vaginal infection The infant is treated with antifungal medication such as nystatin suspension A cleft lip or palate results if the lip or palate fails to close Cleft palat may involve the hard or soft palate or both and may appear alone or with a cleft lip. The palate is inspected when the infant cries A gloved finger is inserted into the mouth to palpate the hard and soft palate. A very small cleft of the soft palate may be missed if only a visual examination is done.

Measurements

Measurements provide info about the infants growth in utero The weight, length, and head and chest circumferences are part of the initial assessment The measurements are compared with the norms for the infants gestational age When a difference is noted between the expected and actual values, expanded assessments are necessary

Skin

Milia: White cysts, 1-2 mm in size, that disappear without treatment They occur on the face over the forehad, nose, cheeks, and chin Erythema Toxicum: Red, blotchy areas with white or yellow papules or vesicles in the center Commonly called flea bite rash or newborn rash and resembles small bites or acne The rash occurs in as many as 70% of newborns It appears during the first 24-48 hours afer birth and can continue for several days to several months It is most common over the face, back, shoulders, and chest The condition does not result from infection but should be differentiated from a pustular rash caused by staph infection or vesicles from herpes simplex Birthmarks: The size color, location, elevation, and texture of all birthmarks should be carefully documented. Mongolian Spots: Bluish gray marks that resemble bruises on the sacrum, buttocks, arms, shoulders, and other areas Occur most frequently in newborns with dark skin. Usually disappear after the first few years of life, some might continue into adulthood Nevus Simplex: also called salmon patch, stork-bite, or ectatic nevus Flat, pink discoloration from dilated capillaries that occurs on the eyelids, just above the bridge of the nose, or at the nape of the neck. The color blanches when the area is pressed and is more prominent during crying The lesions disappear by 2 years of age, although those at the nape of the neck may persist Nevus Flammues: also called Port-Wine Stain Flat, pink to dark reddish-purple mark that varies in size and location and does not blanch with pressure The lesion may darken and may become nodular as the child gets older If it is large and in a visible area, it can be lightened by laser surgery, which is often begun in infancy Lesions located over the forehead and upper eyelid may be assoc with Sturge-Weber Syndrome, a serious neurologic condition. Nevus Vasculosus: Strawberry Hemangioma Consists of enlarged capillaries in the outer layers of the skin It is dark red and raised with a rough surface, giving a strawberry-like appearance The hemangioma is usally loated on the head.It may be present at birth or develop by 6 months of age After growing larger for 6 months, the hemangioma regresses over several years and disappears. Treatment is NOT necessary unless it becomes infected or ulcerated

Urine

Most newborns void within 12-24 hours of birth and a few within 48 hours of birth Bc absence of urine output during this time may indicate anomalies, the first void should be carefully notes on the chart The newborn's bladder empties as little as once or twice during the first 2 days, although more frequent voiding is common BC of the small amt, the first void may be missed Sometimes it occurs in the delivery room but goes unnoticed because attention is focused on the infants overall condition. If there is a concern about whther the newborn has urinated, the delivery notes should be carefully read to see if the infant voided at birth. The nurse should ask the mother is she has changed a wet diaper. Increasing the infants fluid intake often can initiate urination. If no void occurs in the expected time, the infants fluid intake should be increased and the physician or nurse practitioner alerted. By the 5th day of life, at least 6 wet diapers can be expected daily. Each void is recorded in the infants chart, including the number of diapers changed by the mother The total number is correlated with that appropriate for the age of the infant Mothers should be taught that at least 6 wet diapers by the 4th day indicate the infant is taking adequate fluid If an infant is having feeding difficulties, noting the number of wet diapers is esp important Disposable diapers are very absorbent and the pale color of the newborns urine may cause very little color change on the diaper Wet diapers generally feel heavier than dry ones If necessary, the nurse can put on gloves and take the diaper apart to examine it The absorbent inner lining is damp if urine is present Cotton balls or tissue placed in the diaper also may be used to increase visibility of small amounts of urine The newborns urine may contain uric acid crystals that cause a reddish pink stain on the diaper. This is known as brick dust staining and may be frightening to parents, who may think the infant is bleeding It does not continue beyond the first few days as the kidneys mature

Head

Newborns head and neck comprises one fourth of the body surface The head is palpated to assess the shape and identify abormalities Cesarean not perceded by labor usually has a round head Vaginal birth usually has some molding Breech position head may be flattened on top Hair should be fine with a consistent pattern Abnormal hair growth patterns may indicate genetic abnormalities A small, red mark is apparent if a fetal monitor electrode was inserted intot he skin of the scalp. LAter, a small scab forms. Occasionally this area becomes infected and topical antibiotics are applied Molding: Refers to changes int he shape of the head that allow it to pass through the birth canal. It is caused by overriding of the cranial bones at the sutures and is common, esp after a vag delivery The parietal bones often override the occipital and frontal bones, and a ridge can be felt at those areas. The condition generally resolves within a few days to 1 week after birth. Often, dramatic improvement is seen by the end of the first day of life. Parents may need reassurance that the infant;s head is normal. All sutures should be palpated. Separation may be the temp result of molding or, if it persists or widens, may indicate increased intracranial pressure. If no space is found between the suture lines, it may be the result of molding and overriding of the bones. Howeer, a hard, ridged area not resulting from molding may indicate premature closure of the sutures. This condition, called craniosynostosis, may impair brain growth and the shape of the head and requires surgery.

Weight

Newborns weight ranges between 2500-4000 g (5-8 ish lbs) If the infants weight is outside the normal range, possible causes are assessed. Factors affecting weight include gestational age, placental functioning, genetic factors such as race and parental size, and maternal diabetes, HTN, and substance abuse Infants are weighed each day they are in the birth facility and at follow-up visits They can be expected to lose up to 10% of their birth weight during the first week of life The loss results from excretion of meconium, normal loss of extracellular fluid, and inadequate intake of calories during the first few days Infants normally regain or exceed their birth weight by 14 days of life Thereafter they gain approx 30 g/day during the arly months

Self-Consoling Activites

Normal newborns are able to console themselves for a short period of time. Self-consoling behaviors include bringing their hands to their mouth, sucking on their fists, listening to voices, and watching objects in the environment. Infants who are ill, preterm or exposed to drugs prenatally have less ability to console themselves.

Blood Pressure

Not a necessary part of a routine assessment BP taken on all extremities if the infant has unequal pulses, murmurs, or other signs of cardiac complications Doppler ultrasonography or other electronic measurement techniques are used Infant should be quiet when the BP is taken, crying can elevate BP A cuff that is too narrow can give false high reading, a cuff that is too wide can give a false low reading Average BP for full-term infant is 65-95/30-60 Hypotension may occur in the sick infant The BP of the lower extremities should be the same or slightly higher than that of the upper extremities A systolic BP in the upper extremities that is greater than 20 mm Hg higher than that in the lower extremities may indicate coarctation of the aorta

Neck and Clavicles

Nurse assesses the infants neck visually and notes the ease with which the head turns from side to side The neck is very short Webbing may indicate Turners Syndrome or Down Syndrome An unusually large fat pad between the occiput and the shoulders may indicate a chromosomal anomaly No masses should be present When lying in a prone position, the term newborn should be able to raise the head briefly and turn it to the other side. Fractures of the clavicle are more likely to occur in large infants, esp when shoulder dystocia occurred Sliding the fingers along each clavicle while moving the infants arm helps identify a fractured clavicle If a fracture is present, a lung, swelling, or tenderness over the bone may be observed Crepitus (grating of the bone) and movement of the bone may be felt during palpation Decreased movement of the affected arm also may occur A difference in the movement of the arms is esp noticeable when the Moro reflex is elicited Injury to the brachial plexus may cause paralysis of the arm on the side of the fracture Treatment of a fractured clavicle includes immobilization of the affected arm for a short time The fracture heals quickly

Breasts

Nurse notes placement of the nipples and looks for extra (supernumerary) nipples, which may appear on the chest or in the axilla. Occasionally, the breasts become engorged and secrete a small amount of white fluid (sometimes called witch's milk) a few days later This condition is caused by maternal hormones and resolves within a few weeks without treatment The breasts should not be expressed or manipulated, as this could cause infection.

Orientation

Nurse notes the infants orientation (ability to pay attention) to interesting visual or auditory stimuli It is most prominent during the quiet alert state Infants focus their eyes and turn their heads toward a stimulus in an attempt to prolong contact with it Preterm and ill neonates have less ability to orient to stimuli

Behavioral Changes

Nurses assess the infant's behavior and alert the physician to abnormalities Assessment includes the 6 different behavioral states: quiet sleep, active sleep, drowsy, quiet alert, active alert, crying Movement between states should be smooth and not abrupt The Brazelton Neonatal Behavioral Scale is often used when detailed knowledge about the infant is needed. In addition to assessing behavioral states, the scale analyzes other aspects of newborns behavior, such as orientation, habituation, self-consoling behaviors, social behaviors, and the appropriateness of the amount of time in each of these activities

SUMMARY OF NEWBORN ASSESSMENT TABLE

P. 402 STUDY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

GU System: Kidney Palpation

Palpation of the kidneys is not usually performed as part of the routine nursing assessment The HCP palpates kidneys just above the level of the umbilicus on each side of the abdomen during the first hours after birth Abd masses may indicate enlargement or tumors of the kidneys Kidney anomalies may accompany other defects bc a problem early in fetal development may affect several organs vulnerable at that time Ex:Infants with only one umbilical artery or defects involving the ears may have renal anomalies. The nurse should observe carefully for urinary output in these infants to determine if the kidneys are functioning adequately

Assessment of Body Systems

Reflexes: Assessment of reflexes is important to determine the health of the newborn;s central nervous system. The nurse notes the presence and strngth of the reflexes and whether both sides of the body respond symmetrically A diminished overall response occurs in preterm and ill infants Absence of reflexes may indicate a serious neuro problem Asymmetric responses may indicate that trauma during birth caused nerve injury, paralysis, or fracture Some newborn reflexes gradually weaken and disappear over a period of months

Hepatic Assessment

Related to blood glucose and bilirubin conjugation

Brachial and Femoral Pulses

Should be present and equal bilaterally Brachial = antecubital space Femoral = at the groin Rates should be the same Femoral pulses that are weaker may result from impaired blood flow in coarctation of the aorta, a congenital heart defect In this condition, a narrowed area of the aorta impedes blood flow to the lower part of the body and causes weaker pulses in the lower extremities

Heel to Ear

Similar to the measurement of the popliteal angle However, the nurse graps the infants food and pulls it straight up alongside the body toward the ears while the hips remain flat on the surface of the bed When resistance is felt, the position of the foot in relation to the head and the amount of flexion of the leg are compared with the diagrams The more resistance and flexion, the more mature the infant

Signs of Respiratory Distress

Tachypnea: A RR of more than 60, it's the most common sign of resp distress. It is not unusual during the first hour after birth and during the periods of reactivity, but continued tachypnea is abnormal Retractions: Occur when soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. The Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present The muscles above the sternum and around the clavicles also may be used to aid in respirations (supraclavicular retractions) Retractions may be mild or severe, depending on the degree of resp difficulty. *Occasional mild retractions are common immediately after birth but should not continue after the first hour* Flaring of the Nares: A reflex widening of the nostrils occurs when the infant is receving insufficient oxygen Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs. Intermittent flaring may occur in the first hour after birth. Continued flaring indicates a more serious resp problem. Cyanosis: A purplish blue discoloration indicating the infant is not getting enough oxygen May be preceeded by a dusky or gray hue to the skin Central cyanosis involves the lips, tongue, mucous membranes, and trunk and indicates true hypoxia. This means that not enough oxygen is reaching the vital organs and requires immediate attention. Bruising of the face may occur from a tight nuchal cord or pressure during birth and may look like central cyanosis. To differentiate cyanosis from bruising, apply pressure to the area. *A cyanotic area will blanch, but a bruised area remains blue.* Central cyanosis in infants with dark skin tone can be checked by looking at the color of the mucus membranes A pulse ox is used to determine oxygen saturation in infants with cyanosis Central cyanosis must be differentiated from acrocyanosis, which is peripheral cyanosis involving only the extremities Acrocyanosis is normal during the first day of birth and if the infant becomes cold It results from poor perfusion of blood to the periphery of the body

Assessment of Thermoregulation

Temp taken soon after birth while infant is being held by mother or in a radiant warmer with a skin probe attached to the abdomen Probe should NOT be attached over bony prominences or areas of brown fat The probe allows the warmer to measure and display the infants skin temp continuously The temp control is set to regulate the amount of heat produced according tot he infants skin temp The temp should be assessed at least once every 30 min until the infant has been stable for 2 hours Often checked at 4 hours then every 8-12 hours Most common location is axillary temp (97.7-99.5 F) Axillary temp is safer than rectal temp bc it avoids the possibility of irritation or injury to the rectum, which turns at a right angle approx 3 cm from the anal sphincter Location of temp should always be charted If rectal temp is necessary, the nurse should use great care bc inserting the thermometer too far could cause potentialy fatal perforation of the intestinal wall A thermometer should never be forced into the rectum bc of the possible presence of an imperforate (closed) anus Temps are usually measured with an electronic digital thermometer Mercury thermometers are no longer used bc of the possibility of injury or contamination with mercury if thermometer breaks Inexpensive digital thermometers used while the infant is int he hospital are often given to the parents for home use Disposable plastic strips that change color to indicate temp readings are used less often than electronic models Tympanic thermometers, used in some facilities for older infants and children, are not recommended for newborns at this time Some agencies use temporal artery thermometers

Assessment Tools

The New Ballard Score is often used to assess gest age based on neuromuscular and physical characteristics Designed to assess gest age from 22-44 weeks and provides accurate info within 2 weeks Most accurate when performed within 12 hours of birth A score is given to each assessment and the total score is used to determine the gestational age of the infant

Gestational Age and Infant Size

The appropriateness of the neonate's size for gest age is determined by plotting the weight, length, head circumference, and gest age on a graph of intrauterine development This score determines how well the infant has grown for the amount of time spent in the uterus An infant may be small, large, or of appropriate size for gestational age The infant whose size is appropriate for gest age falls between the 10th and 90th percentiles on the graph The LGA infant is above the 90th percentile, whereas the SGA infant is below the 10th percentile

Head and Chest Circumference Study table p. 391

The diamter of the head is measured around the occiput just above the eyebrows The normal range of head circumference for the term newborn is 32-38 cm (13-15 in) The measurement may be affected by molding of the skill during the birth process. If a large amount of molding occurred, the head is remeasured when it regains its normal shape An abnormally small head may indicate poor brain growth and microcephaly. A very large head may be a sign of hydrocephalus The chest is measured at the level of the nipples. It is usually 2-3 cm smaller than the head The normal circumference of the chest is 30-36 If molding of the head is present, the head and chest measurements may be equal at birth

Ear

The ears assessed for placement, overall appearance, and maturity An imaginary horizontal line drawn from the outer canthus of the eye should be even with the area where the upper ear (helix) joins the head Low-set ears may indicate chromosomal abnormalities The ears should be almost vertical in placement on the head An angle greater than 10 degrees is abnormal The nurse examines the ears for skin tags and preauricular sinuses and dimples If they occur with any other abnormalities, a renal ultrasound is often performed Abnormalities of the ear may indicate chromosomal abnormalities, hearing probs, or kidney defects The stiffness of the cartilage and degree of incurving of the pinna are checked as part of gestational age assessment Hearing begins to develop by 23-24 weeks gestation Infants can hear by the last trimester of pregnancy, and their hearing is very good after birth Hearing is assessed by noting the infants reaction to sudden loud noises, which should cause a startle response Infants should respond to the sound of voices and prefer a high pitched tone of voice and rhythmic sounds They will turn toward the sound of the mother's voice or another interesting sound A hearing screening is performed before discharge from most birth facilities

Eyes and Ears

The eyelids are fused until 26-28 weeks of gestation When the ear is assessed, the incurving and thickness of each pinna are rated At about 34 weeks of gestation, the upper pinnae, which have been flat, begin to curve over The incurving continues around the ear until it reaches near the earlobe at 40 weeks of gestation The amount of cartilage present in the ears is a more accurate guide to gestational age than the incurving of the pinnae bc of the individual differences in ear shape As cartilage is deposited in the pinnae, the ears become stiff and stand away from the head. The ear is folded longitudinally and horizontally to assess the resistance and speed with which the hear returns to its original state. In infants less than 34 weeks of gest, the ear has little cartilage to keep it stiff When folded, it remains folded over or returns slowly. In the term neonate, the ear springs back to its original position immediately.

Eyes

The eyes are examined for abnormalities and signs of inflammation The should be symmetric and of the same size The iris is dark gray, blue, or brown but may change color by 6 months of age Slanting epicanthal folds in non-asian infant may be a sign of trisomy 21 or other abnormal conditions Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which cause capillary rupture in the sclera The edema diminishes in a few days, and the hemorrhages resolve in 7-10 days The sclera should be white or bluish white. A yellow color indicates jaundice A blue color occurs in osteogensis imperfecta, a congenital bone condition Conjuctivitis may result from infection or a chemical reaction to meds Staph, chlamydia, neisseria gonorrhea, are common organisms that cause infection Maternal gonorrhea can cause infection of the infant during birth The resulting opthalmia neonatorum may cause blindness To prevent this condition, all newborns are treated prophylactically with antibiotics to the eyes Any discharge from the eyes is reported for possible culture and treatment Transient strabismus (crossed eyes) is common for the first 3-4 months after birth bc infants have poor control of their eye muscles The doll's-eye sign is a normal finding in the newborn: When the head is turned quickly to one side, the eyes move toward the other side The setting-sun sign (the iris appears low in the eye and part of the sclera can be seen above the iris) may be an indication of hydrocephalus The pupils should be equal in size and react equally to light Cataracts (opacities of the lens) appear as white areas over the pupils They may develop in infants of mothers who had rubella or other infections during the pregnancy When a light is directed into the eyes, the normal red reflex may not be seen if large cataracts are present Tears are scant or absent for the first 2 months of life Excessive tearing may indicate a plugged lacrimal duct, which is treated with massage or surgery

Hands and Feet

The fingers and toes are examined for extra digits (polydactyly) and webbing between digits (syndactyly) Extra digits are often small and may not have bones Tying the extra digits with sutures causes them to atrophy and fall off The presence of a bone in the extra digit requires surgical removal Webbed fingers or toes may be corrected by surgery Nails in a term infant should extend to the end of the fingers or slightly beyond The creases in the hands also are examined Normally, 2 long transverse creases extend most of the way across the palm A single crease parallel with the base of the fingers that crosses the palm without a break is called simian crease or line It may be seen with incurving of the little finger in Down syndrome The simian line alone is not a diagnostic of trisomy 21 (Down syndrome) The feet are assessed for talipes equinovarus, or club foot, a common malformation of the feet If a foot looks abnormal, it should be gently manipulated If it moves to a normal position, the abnormality is prob temporary, resulting from the position of the infant in the uterus In the club foot, the foot turns inward and cannot be moved to a midline position Casting and manipulation are the usual treatment, but sometimes surgery is necessary

Admission Assessment

The first complete assessment of the newborn

Hair and Nails

The hair on a full-term infant should be silky and soft, whereas the hair on a preterm infant is woolly or fuzzy. The nails come to the end of the fingers or beyond Very long nails may indicated a postterm infant A green-brown staining of the nails may occur if the infant passed meconium before birth. It is a sign of possible fetal distress. The umbilical cord may also be stained

Extremities

The infant should actively move the extremities equally in a random manner The extremities of a term infant should remain sharply flexed and resist extension during examination Poor muscle tone results in a limp or floppy infant, which may occur from inadequate oxygen during birth but should resolve within a few minutes as oxygen intake increases Continued poor muscle tone may result from prematurity or a neurologic injury *Infants with previously good muscle tone may show decreased flexion if they become hypoglycemic or experience resp difficulty* All extrems are examined for signs of fractures such as crepitus, redness, lumps, or swelling Lack of use of an extremity may indicate nerve injury that may occur with or without fractures Injury to the brachial nerve plexus may result in Erb's palsy, paralysis of the shoulder and arm muscles Instead of the usual flexed position, the affected arm is extended at the infants side with the forearm prone Movement of this arm is diminished during the Moro reflex The condition is treated by splinting, exercise, or both

Length

The infants length is measured from the top of the head to the heel of the outstretched leg The average length of a full-term newborn is 48-53 cm Some agencies also record the crown-to-rump measurement, which is approximately equal to the head circumference

Habituation

The infants response to a visual, auditory, or tactile stimulus is an important assessment Generally, the first response of a healthy newborn to an interesting stimulus such as a brightly colored object or bell, is a period of alertness. If the stimulus is disturbing, like a bright light flashed in the eyes, the infant startles and attempts to escape by averting eyes Infants gradually stop responding to continued unpleasant stimuli This gradual habiuation allows them to ignore the stimuli and save energy for physiologic needs Newborns may display a dull, drowsy state or fall into a deep sleep. Those who seem unresponsive in a bright, noisy environment may be in a state of habituation The preterm infant or one with damage to the central nervous system may not be able to habituate.

GI System

The initial assessment of the GI tract occurs during the first hours after birth, when the nurse visualizes the parts that can be seen and the infant takes the initial feeding

Other Neurologic Signs

The newborn is assessed for tremors or jitteriness If tremors are present, the blood glucose should be checked bc hypoglycemia is the most common cause If blood glucose is within normal range, the cause may be low calcium or prenatal exposure to drugs Tremors increase each time the infant is touched or moved but stop briefly if the extremity is flexed and held firmly Seizures indicate central nervous system or metabolic abnormality To differentiate between tremors and seizures, the infant's extremities are held in a flexed position This causes tremors to stop, but a seizure continues Seizure activity may also include abnormal movements of the eyes and mouth and other subtle signs Any infant thought to be having seizures is referred for further assessment and treatment The pitch of the cry is important. Cries that are shrill, high-pitched, hoarse, and catlike (mewing) are abnormal. These cries may indicate a neurologic disorder or other problem. Normal infants respond to holding and are quiet and appear content when their needs are met Rocking motions are often effective in quieting an irritable infant Most infants nestle or mold their bodies to that of the peple holding them, making them easy to hold and cuddle Neonates who stiffen the body, pull away from contact, or arch the back when held may be showing signs of CNS injury Infants should react to painful stimuli with crying and an increase in vital signs Excessive irritability also may be a sign of injury to the CNS All such abnormal signs are reported for further neruologic assessment

Breasts

The nipples, areola, and size of the breast buds are associated and scored In very preterm infants, the structures are not visible Gradually, they grow larger and the areolae become raised above the chest wall The breast buds enlarge until they are approximately 1 cm at term To determine their size, the nurse places a finger on each side and measures the diameter Use of the thumb and forefinger may cause excess tissue to be drawn together, resulting in an inaccurate score.

Suck

The normal full-term infant should have a strong suck reflex, which is elicited when the lips or palate are stimulated The reflex is weaker in the neonate who is preterm, is ill, or has just been fed, The newborn's cheeks have well-developed muscles and sucking pads that enhance the ability to suck. These fatty sucking pads last until late in infancy, when sucking is no longer essential Blisters may be present on the newborns hands or arms from strong sucking before birth

Bilirubin

The nurse assesses for jaundice at least every 8-12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia *Jaundice is identified by pressing the infants skin over a firm surface, such as the end of the nose or sternum* The skin blanches as the blood is pressed out of the tissues, making it easier to see the ywllow color that remains Jaundice is more obvious when the nurse assesses in natural light Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin is greater than 5 mg/dL *Jaundice appearing before the second day of life may indicate the bilirubin level is rising more quickly and to higher levels than normal and may not be physiologic* The physician may order lab determinations of the bilirubin level based on the nurse's assessment In many facilities, protocols allow the nurse to obtain transcutaneous bilirubin measurements using bilirubinometer or lab measurement of total serum bilirubin without the order of a nurse practitioner or physician. A bilirubinometer is a noninvasive device to measure bilirubin in the infants skin, thus avoiding repeated skin punctures to obtain blood samples OBtain TSB ot TcB measurements on all infants jaundiced within the first 24 hours If serial bilirubin assays are ordered, the nurse notes changes from one reading to the next and correlates the results with the infants age Abnormal results of TcB should be confirmed by measurement of TSB Charts are available that show the degree of risk for infants at different ages (in hours) by the level of TSB TSB or TcB should be measured before discharge This helps determine if discharge should be documented and reported to the physician

Scarf Sign

The nurse grasps the infants hand and brings the arm across the body to the opposite side, keeping the shoulder flat on the bed and the head in the middle of the body The position of the elbow in relation to the midline of the infants body is noted The infant receives a score of 0 if muscle tone is so poor that the arm wraps across the body like a scarf with the elbow beyond the edge of the body A top score of 4 shows that the elbow fails to reach the midline

Neuromuscular Characteristics

The posture and degree of flexion of the extrems are scored before disturbing the wuiet infant Preterm neonates have immature flexor muscles and little energy or muscle tone Therefore, they have extended, limp arms and legs that offer little resistance to movement by examiner Flexor tone improves at the gest age increases and it moves in a cephalocaudal manner down the infants body Full-term infants hold their arms close to the body with the elbows sharply flexed The legs should be flexed at the hips, knees, and ankles Posture is scored from zero for a limp, flaccid posture to 4 if the newborn demonstrates good flexion of all extrems The legs of infants who were in a frank breech position may be more extended than flexed even when they are full term

Color

The skin color should be pink or tan Red, thin skin occurs in preterm infants Redness (ruddy color or plethora) in the full-term infant may indicate polycythemia Acrocyanosis is common during the first day as a result of poor peripheral circulation *The infants mouth and central body areas should not be cyanotic at any time!* Blanching the skin over the nose or chest shows the presence of jaundice. Jaundice is abnormal during the first day of life but common during the first week. A greenish-brown discoloration of the skin, nails, and cord results if meconium was passed The discoloration may indicate that the infant was compromised at some time before birth, and it is more common in the postterm infant These infants must be watched for other complications such as respiratory difficulty Harlequin Color Change: A clear color division over the body with one side deep pink or red and the other half pale or of normal color. The cause is vasomotor instability and it is usually transient and benign Mottling: A lacy, red or blue pattern from dilated blood vessels under the skin. It is usually from vasomotor instability, occurring when the infant is exposed to cold, stressed, or overstimulated If persistent, it may indicate a chromosomal abnormality Vernix Caseosa: A thick, white substance that resembles cream cheese, provides a protective covering for the fetal skin in utero The full-term infant has little vernix left on the body except small amounts in the creases. A thick covering of vernix may indicate a preterm infant and a postterm infant may have none at all Lanugo: Fine, soft hair that covers the fetus during intrauterine life As the fetus nears term, the lanugo becomes thinner The term infant may have a small amount of lanugo on the shoulders, forehead, sides of the face, and upper back. Dark-skinned infants often have more lanugo than infants with lighter coloring, and their darker hair is more visible. Lanugo is assessed as part of the gestational age assessment