Newborn Assessment Part 2

Respiration -Normal breathing rate ___ to __ -Predominantly diaphragmatic, w/ associated rising and falling of ab___ during inspiration and expiration -Hyperexpansion (chest appears h____) or hypoexpansion (chest appears l__) of diameter should also be noted

30 to 60 abdomen high; low

Brazelton Neonatal Assessment Scale -Assessment tool that identifies the newborn's repertoire of b___ responses to the environment and also documents the newborns n___ adequacy and capabilities

behavior neuro

Skin characteristics -Acrocyanosis- b___ discoloration of the hands and feet- may be present first __ hrs after birth -due to poor p____ circulation -blue hands and nails poor indicator of oxygenation in newborn -Face and mucous membranes should be assessed for pinkness

bluish, 24 peripheral

Hands -Nails extend beyond fingertips -Fingers and toes should be c___ -Polydactyly- presence of extra d__ on either hand or feet -Syndactyly- fusion (w____) of fingers or toes (hereditary or trisomy 21) -Hands inspected for normal palmar creases (1=trisomy 21)

counted digits webbing

Rooting reflex -Elicited when side of the newborn's m__ or c__ is touched -Newborn turns toward that s__ and opens the lips to s__

mouth/ cheek side/ suck

Sucking reflex -Elicited when an object is placed in the newborns m__ or anything touches the l__ -may even suck while sleeping (nonnutrive sucking for quieting)

mouth/ lips

Eyes -Transient strabismus- gradually regresses in __-__ months -doll eye phenomenon- 10 days after birth- head position changes, eyes move to opposite direction

3-4

Umbilical cord -Cord bleeding is ab___ and may result from tension on the cord or clamp b/c the cord was inadvertently p__ or b/c the cord clamp was l___ -f__-smelling drainage= abnormal and r/t i___--> requires immediate attention to prevent s__ -Serous/ serosanginous drainage that continues after the cord falls off may indicate granuloma

abnormal pulled/ loosened foul smelling, infection; sepsis

Neuro assessment -Assess the state of a___ ness, r___ posture, c__, and quality of muscle t___ and motor a__ -Usual position of newborn is paritally f___ extremities w/ the legs abducted to the abdomen -When awake, may exhibit purposeless, uncoordinated bilateral movements of the extremities -if these movements, absent, minimal or obviously asymmetrical, neurologic dysfunction suspected -Eye movements observable during the first few days of life -Alert newborn able to fixate on f___ and brightly colored objects -Shining a bright light in eye eilicts b___ response

alertness, resting, cry, muscle tone and motor acitivity flexed faces blinking

Male genitalia -Penis inspected to determine if urinary orifice is correctly positioned -Hypospadias- occurs when the urinary meatus is located on the ventral surface of the penis -Epispadias- on dorsal surface of penis -Phimosis-Opening of the foreskin cannot be pulled back over glans at a__- may interfere w/ u___

all urination

Mouth -precocious teeth- if appear loose should be removed to prevent a___ -Epstein pearls- glistening w___ specks that feel h__ to the touch- disappear in a few weeks- no significance -Thrush- may appear as wh__ patches that look like milk curds adhering to the mucous membranes- bleeding may occur when patches removed -caused by candida albicans- acquired from infected v__ tract during birth, antibiotic use and poor h__ washing when handling newborn mother may be treated at the same time

aspiration white; hard white tract handwashing

Respiration -both the anterior and posterior chest are au___ -Some breath sounds are heard best when infant c___, but it is difficult to localize and identify breath sounds in the newborn -Upper airway noises and bowel sounds can be heard over the chest wall, making auscultation difficult -Because sounds may be transmitted from the unaffected lung to the affected lung, the absence of breath sounds may not be d___

ausculatated crying diagnosed

Eyes -Subconjuntival hemorrhages- commonly found on sclera -caused by changes in vascular tension or ocular pressure during birth -remain for few weeks, no patho. significance -Parents need reassurance eye not b__ and vision is not im__

bleeding impaired

Female genitalia -Examines labia majora, minora and clitoris, size appropriate for age -vaginal/ hymemal tag often evident and will usually disappear in a few weeks -During first week of life, may get discharge composed of thick whitish mucous which can become tinged w/ b___ (pseudomenstraution)- caused by withdrawal of maternal h___ -Smegma= white cheeselike substance often present between labia- removal may traumatize tender tissue

blood hormones

Cephalohematoma -collection of b___ between cranial bone and periosteal membrane -does not cross s___ lines -Doesn't increase in size w/ c___ -appears f__- to s___ days -Disappears after 2-3 weeks or may take months -may be associated w/ physiologic jaundice -may lead to anemia and hypotension

blood suture crying first/ second

Heart -Peripheral pulses (b___, f___ and p__) evaluated to detect any lags or unusual characteristics -Brachial pulses are palpated bilaterally for equality and compared with f___ pulses -Femoral pulses are palpated by applying gentle pressure over the femoral canal -Decreased/ absent femoral pulses= coartiction of the aorta or hypo___ --> further investigation -Wide difference in BP from upper and lower extremities also indicates coarctation of the aorta

brachial, femoral, pedal femoral; hypovolemia

Nose -small and narrow -nose b___ for the first few months of life -generally remove obstructions by s___ -nose patent if newborn breathes easily w/ mouth c___ -ability to smell- turn head towards m___ source

breathers sneezing closed milk

Neonatal seizures -May consist of no more than c___ or s___ movements, deviation of the e___, rig___ or f___ b/c of CNS immaturity -Seizures not usually initiated by stimuli and cannot be stopped by h___

chewing or swallowing; eyes, rigidity, flaccidity holding

Abdomen -Abdominal palpation should be carried out systematically -Nurse palpates each of the four abdominal quadrants, moving in a cl___wise direction, checking for softness, tenderness and the presence of masses -Nurse should place one hand under the back for support during palpation -When palpating nurse may feel for the l___- is large in proportion to the rest of the body

clockwise liver

Fontanelles -Useful indicator of the newborns condition -Anterior may swell when the newborn c__ or passes a st__, or may pulsate w/ heartbeat= n___ -Bulging fontanelle= increased intracranial p_____ -Depressed fontanelle= de_____ -Sutures between cranial bones should be paplated for amount of overlap -newborns whose growth has been restricted, sutures may be wider and larger than normal -head should be assessed for degree of m___ and s___, head should be evaluated for soft-tissue e___ and b___

cries or passes a stool normal pressure dehydration molding and size, edema and bruising

Barlow maneuver -rule out the possibility of developmental dysplasic hip (congenital hip dysplysia)- examiner grasps and adducts the infants thigh and applies gentle downward pressure. Disl___ is felt

dislocation

Respiration -Air e___ may be noisy in the first couple of hours until lung f__ resolves, especially in cesarean births -Brief periods of apnea (episodic breathing) may occur, but no H__ or c__ changes in healthy, term babies -S___ should be suspected in full-term infants experiencing apneic episodes

entry, fluid HR or color sepsis

Eythema toxicum- eruption of lesions in the area surrounding a hair follicle that are firm w/ a white or yellow papsule w/ an e___ base

erythmeous

Signs of respiratory distress -Nasal f__ -Intercostal or xiphoid re___ -Expriatory g___ or sighing -S___ respirations -T___ (sustained or resp. >60)

flaring retractions grunting seesaw tachypnea

Chest -Thorax cylindric and symmetric at birth -Ribs= f___ -Protrusion at end of sternum- xiphoid cartilage-frequently seen- under the skin and will become less apparent after several weeks as the infant accumulates adipose tissue

flexible

Caput succedaneum -Collection of f____, edematous s___ of the s___ -Crosses s___ lines -Present at b___ or shortly after -Reabsorbed within 12 hours or few days after birth

fluid; swelling; scalp suture birth

Ears -are soft and pliable -Should recoil readily when f___ and re___ -In normal newborn, top of the ear (pinna) should be p___ to the outer and innter canthus of the eye -Ears should be inspected for size, shape, position and firmness of cartilage -Low-set ears- characteristic of many s____ and may indicate c___ abnormalities -can discriminate individual characteristics of a h___ voice -Universal newborn hearing s___done

folded and released parallel syndromes; chromosomal human screening

Neck -Clavicles evaluated for evidence of f___ (can occur during difficult births or newborns w/ broad shoulders) -Normal clavicle= s____ -If fractured, l___ and grating sensation (crepitus) during movements may be palpated along the course of the side of the break -The M__ reflex is also elicited to evaluate bilateral movement of the arms -If clavicle fractured, this response will be demonstrated only on the una__ side

fractures straight lump Moro unaffected

Nevus vasculosus (s___ mark) -Capillary hemangioma -Consists of newly formed and enlarged capillaries in the dermal and subdermal layers -Raised, clearly delinated, dark, red, rough surfaced birth mark commonly found in the h__ region -Begin to grow rapidly during the second/third week of life- may not reach full size until 6 months -Begin to s___ and resolve spontaneously several weeks/months after peak growth -pale purple/ grey spot= start of resolution

head shrink

BP -May not be routinely measured in h___ newborns but essential in those having di___, pre___, cardiac anamoly, r___ disease or clinical signs of hypot___ -Infants who have birth asphyxia are on ventilators have significantly lower BP -If cardiac anamoly suspected, BP palpated in all four extremities -Systolic at birth: __- __ -Diastolic at birth: __-__ -day 10: 90/50 -obtain two to three BPs and take mean

healthy distress; premature, renal; hypotension 50-70 30-45

Heart -placement of the heart in the chest should be determined when the newborn is in a quiet state -The heart is relatively large at birth and is located mid to left chest and h__ in the chest, w/ apex somewhere between ___ and __ intercostal space

high fourth and fifth

Chest -Engorged breasts occur frequently in both males and females -This condition (appears 3rd day) is a result of maternal h__ influences and may last up to 2 weeks -w___ish secretion from the nipples may also be noted -infants breast should not be m__ or s__- may cause breast abscess -Supernumerary nipples are occasionally noted below and medial to the true nipples- these are harmless p__ or b__ spots vary in size and don't contain glandular tissue -Accessory nipples can be differentiated from mole by placing fingertips alongside the accessory nipple and pulling the adjacent tissue laterally.- accessory nipple will d___

hormonal whitish massaged or squeezed pink or brown dimple

Eyes -Erythromycin in the eyes- may cause edema and chemical conjuctivitis- which may appear few h___ after instillation and disappear in __ to __ days -if infectious conjuctivis exists, newborn has some purulent drainage (greenish yellow) but cause by bacteria and requires ophthalmaic antibiotics- onset usually after second day

hours 1-2

Skin turgor- assessed to determine h___ status, the need to initiate early feedings, and the presence of any infectious processes

hydration

Neuro assessment -Tremors and jitteriness (tremorlike movements) in the full-term newborn must be evaluated to differentiate from convulsions -Tremors may be r/t hypog____, hypoca___ or substance w___ -Jitteriness may be distinguished from tonic-clonic seizure activity b/c it can usually be stopped by the infants sucking on the e___ or by the nurse holding or flexing the involved extremity -Fine jumping of the muscle= likely CNS disorder and needs further eval.

hypogylcemia, hypocalecemia or substance withdrawal extremity

BP -measurement of BP best accomplished by using a noninvasive BP device -If BP cuff used, newborn's extremities must be im___ and cuff over 2/3 of upper arm or leg -M__, c___, and inappropriate cuff size can lead to inaccurate measurement

immobilized movement and crying

Feet -Examined for clubfoot -Intrauterine position frequently causes the feet to appear to turn inw___- positional clubfoot -If the feet can easily be returned to the midline by manipulation, no t___ is indicated -ROM exercises taught to family -Further investigation when foot will not turn to the midline position--> Most severe form of club foot (talipes equinovarus)

inward treatment

Head- general appearance -Newborns head is large (1/4 of body size) w/ soft, pliable skull bones -Occipital fontal cirumference- 32-37 cm -may appear asymmetrical in a vertex presentation -molding= asymmetry caused by the overriding of the cranial bones during l__ and b__ -degree of molding varies w/ the amnt. and length of p___ exerted on the head -within a few days after birth, teh overriding usually dim___ and suture lines become palable

labor and birth pressure diminishes

Heart -Pulse rate is variable an is influenced by physical activity, crying, state of wakefulness, and body temp. -Auscultation is performed over the entire heart region (percordium), below the l___ axilla and below the s___ -Apical pulse rates are obtained by auscultation for a full m___, preferably when newborn a__

left; scapula minute, asleep

Erb-Duchenne Paralysis (Erb palsy) -involves damage to the upper arm (5th/6th cervical nerves) and is the most common type -newborn's arm lies l___ at side -Elbow held in extension w/ forearm pronated- Moro reflex cannot be done on affected side -Lower arm injury = paralysis of hand and wrist -Whole arm= paralysis of limb -Some resolve in months, other partially paralyzed and some total

limply

Congenital dermal melanocytosis (m___ spots) -macular areas of b__ bl__ or grey-blue pigmentation commonly found on the dorsal area and the b___ but may appear anywhere on the body -common in Asian, hispanic and african -gradually fade by f__ / s__ year of life -may be mistaken for b___ and need to be d___

mongolian bluish-black buttocks first/ second bruises/ documented

Heart -Can be as rapid as 180 bpm and can fluctuate a great deal, especially if baby m__ or is s___ -Normal range: __-__ -A___ provides nurse w/ valuable assessment -Heart examined for r___ and r___, position of a___ impulse, and heart sound intensity -Dsyrhtymias should be evaluated by p___

moves; startled 110-160 auscultation rate and rhythm; apical physician

Neuro assessment -Nurse evaluates muscle tone by moving various parts of the newborns body while the newborn's head remains in a n___ position -Newborn is somewhat hypertonic- resists the examiner's attempt to extend the elbow and knee joints -Muscle tone should be sy___ -Diminished muscle tone and flacidity require further evaluation

neutral symmetric

Palmar grasping reflexing: -Elicted by stimulating the newborn's p__ w/ a finger or object; the newborn g__ and h__ the object firmly

palm; graps and holds

Face -symmetry of eyes, nose and ears evaluated to assess for the prescence of facial p___ -Facial paralysis appears when the newborn c____, the affected side is immobile and the eyelid fissure widens -may result from forceps assisted birth -disappears few days to 3 weeks; may be permanent

palsy cries

Anus -Inspected to verify it is p___ and has no fissure -Digital exam may need to be done -Meconium should be passed within first __ hrs or suspect complication

patent 24 hrs

Heart -Shift of heart tones in the mediastinal area to either side may indicate p____, dextrocardia (heart placement to the r__ side of chest) or diaphragmatic h___ (experienced nurse can diagnose these early w/ a stethoscope) -Normal heartbeat a tic toc sound- slur or slushing sound may indicate a ___ -90% t___ and are considered n___, should be closely monitored by phy___ -many r/t closing of patent ductus arterious or patent foramen ovale close 1-2 days after birth

pneumothorax, right; hernia murmur transcient; normal physician

Nevus flammeus (port w__ stain) -capillary angioma directly below the epi__ -None__, sharply demarcated, red to purple area of dense c__ -Commonly appears on face -does not grow in s____, does not f__ w/ time and does not b___ -convlusions/ other neuro problems = sturge-weber syndrome

port wine epidermis nonelevated, capillaries size, fade, blanch

Abdomen -Should by cylindrical, protrude slightly and move w/ r___ -Certain amount of laxness of abdominal muscles normal -Scaphoid (hollow shaped) appearance, suggests absence of abdominal co___, seen in diaphragmatic h___ -No cyanosis should be present; few if any blood vessels apparent to e__ -No gross dis__ or b__ -More distended the abdomen, the tighter the skin becomes, and engorged vessels appear -D__ 1st sign of GI abnormalities

respiration contents; hernia eye distention or bulging distention

Head- general appearance -B/c head measurements are affected by molding, a second measurement indicated a couple days after birth -head of breech-born or elective c-section are characteristically r___ and well shaped b/c p__ not exereted on them

round, pressure

Tonic neck reflex -Elicited when the newborn is supine and the head is turned to one s__ -In response, the extremities on the same side st___, whereas on the opposite side they f___

side straighten flex

Herlequin sign- deep color develops over one __ of the newborn's body whild the other side remains p___; resmebles a clown suit -Lasts few seconds to 30 minutes; may have single or multiple episodes, are transient and insignificant, document

side; pale

Extreme differences in head size may indicate: -Microcephaly- an abnormally s__ head -Hydrocephalus- an abnormal buildup of ____ on the brain

small fluid

Head -Two fontanelles (so__ spots) may be palpated on the newborns head -which are openings at the juncture of the c___ b___, can be measured w/ fingers in cm -Assessment should be carried out when the newborn in sit___ position and not c___ -Anterior fontanelle- diamond shaped, juncture of frontal and parietal bones -Posterior fontanelle- smaller and triangular, formed by the parietal and occipital -B/c of molding, fontanelles tend to be smaller immediately after b___ than several days later -anterior close 18 months, posterior- 8-12 weeks

soft cranial bones sitting, not crying birth

Moro reflex: -Elicited when the newborn is s____ by a loud noise or being lifted slightly above the crib and suddenly lowered -In response, the newborn str___ arm and hands outward while the knees fl__ -slowly arms return to chest as in an embrace -fingers spread forming a C and may cry

startled straighten; flex

Telangiectatic nevi (s___ bites) -birth mark -appear as pale pink or re_ spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck -light complexion newborns -more noticable w/ crying -no clinical significance -usually fade by s__ birthday

stork red second

Back -Spine should appear s__ and flat b/c the lumbar and sacral curves do not develop until the infant begins to sit -Base of spine examined for dermal sinus -hairy nevus - associated w/ spina bifida

straight

Crying -Should be s___, lu___ and of medium pitch -High-pitched, s___ cry is abnormal and may indicate n___ disorders or hypo___ -Periods of crying vary in length after consoling measures are used -baby's cries are an important method of c____ and alert caregivers to changes in the babys condition and needs

strong, lusty shrill; neurological and hypoglycemia communication

Mouth -lips should be pink and touch on lips should produce s__ motions -saliva- scant -taste buds develop before birth, easily discriminate between sweet and bitter flavors

sucking

Assessing CNS integration -Insert an unpowdered gloved finger into the newborns mouth to elicit a s___ reflex -As soon as the newborn is sucking vigorously, assess h____ and v___ responses by noting sucking changes in the presence of a light, rattle or voice -Newborn should respond w/ brief c___ of sucking followed by continuous sucking w/ repeated stimulation

sucking hearing and vision cessation

Face -well designed to help the newborn s___ -sucking (fat) pads are located in the cheeks and labial tubercle (sucking callus) frequently found in the center of upper lip -chin is recessed, nose flattened -lips sensitive to t____ and sucking reflex is easily i___

suckle touch; initiated

Variations in the shape, size or appearance: -craniosynostosis- premature closure of the cranial s___ which needs to be corrected through surgery to allow brain growth -plagiocephaly- asymmetry resulting in the closure of sutures on one side caused by p_____ on the fetal head during gestation

sutures pressure

Eyes -Crying is commonly ___less

tearless

Male genitalia -Scrotum inspected for size and symmetry -Should be palpated to verify both t____ and rule out cryptorchidism (failure of t___ to descend) -Testes palpated separately between the thumb and the forefinger w/ the thumb and forefinger of the other hand placed together over the inguinal canal -Scrotal edema and discoloration common in b___ births -Hydrocele (collection of f___ surrounding the testes in the scrotum)- common in newborns and should be identified -Usually resolves w/o in___ -Presence of discolored/ dusky scrotum/ solid testis raise suspicion of testicular torsion- reported im___

testes, testes breach fluid intervention immediately

Mouth -Examined by stimulating infants to cry by gently depressing down on the t____, thereby causing them to fully open the mouth -gloved hands -looking for cleft palate

tongue

Mouth -Newborn may be tongue ___- causing heart shape of the tongue -frenotomy- if infant has trouble feeding

tongue tied

Mottling- lacy pattern of dilated blood v___ under the skin -occurs as a result of general circulation fluctuations -may last several hours to several weeks- may come and go periodically

vessels

Neck -Short neck, creased w/ skin folds is characteristic -Muscle tone not well developed= neck cannot support the full w____ of head -Neck palpated for masses and presence of lymph nodes -Adequacy of ROM and neck muscle function determined by moving the head while supporting the newborn to prevent i____ -injury of sternocleidomastoid muscle= presence of neck rigidity

weight injury

Milia- appear as raised w__ spots on the facep especially nose

white

Umbilical cord -Initially, it is w___ and g__ in appearance w/ two umbilical a__ and one umbilical v___ readily apparent -single umbilical artery is frequently associated w/ c___ a__ - vessels should be counted as part of assessment -cord drying begins within 1-2 hrs after birth and is s__ and b___ by 2nd or 3rd day

white; gelatinous arteries; vein congenital anomalies shriveled and blackened

Vernix caseoas- w__ ch__like substance that covers the fetus while in utero and lubricate the skin of the newborn

whitish, cheeselike

Abdomen -Before palpation of abdomen, nurse should a__ for the prescence/ absence of bowel s__ in all 4 quadrants -Bowel sounds should be present __ hour after birth -Palpation can cause transient decrease in bowel sound intensity

auscultate; sounds 1