NUR 113 - Test 4 Reproduction/ Newborn Assessment

Nystagmus

("wandering eyes") and strabismus are commonly seen in the newborn due to weak ocular muscles that control eye movements. This is normal but may cause parents concern. strabismus- cross-eyes

Umbilical cord

1 vein and 2 arteries. If the cord has dried and the vessels are no longer visible, check the birth record for vessel count. The presence of only 1 artery with 1 vein is reported as it may be associated with congenital malformations such as circulatory defects. Also observe the umbilical cord for any bleeding or oozing, redness, warmth, or foul-smelling discharge. Infection of the umbilical cord is potentially serious since it can easily spread, via open vessels, to the peritoneum (report immediately). The cord should begin to dry after 24 hours. A persistently moist umbilicus could indicate a potential problem. Keep an inch available for the cord in case of medications or access needed later

Signs of respiratory distress are:

1st- Tachypnea are usually seen first with nasal flaring 2nd- Expiratory grunting Retractions: intercostal retractions- skin sticking to the ribs subcostal retractions- bulging in the abdomen These may be seen right after birth and will be monitiored and should transition after mother baby attachment Those at risk: Large or small for gestational age Infant of a diabetic mother, lungs dont mature as quickly Interventions: Monitor to see if newborn transitions out Pulse Ox monitor- not the same as adults. 90% is generally okay ( dont need to know) Skin to skin- newborn will usually transition out of this

History: When delivered

A baby born vaginally with a face presentation may evidence marked bruising or petechiae on the face Occiput Posterior delivery which is expected but need to be aware of this. A baby in the breech position may exhibit a posture other than flexed or may have bruised, edematous parts of the lower body Breech trauma A baby who's intrauterine position was frank breech - note how this influences the posture after birth

History: Type of delivery

A baby born via vaginal delivery with the vertex(top of the head) presenting is likely to exhibit molding of the head. A baby born vaginally via forceps may exhibit forceps marks. A baby born vaginally via vacuum extraction may exhibit swelling under the scalp. A baby born via C-section is frequently more prone to respiratory distress and should be observed closely. Tachypnea and coarse, crackling, gurgling lung sounds are frequently heard due to the absence of a traditional "vaginal squeeze" which secretions from a vaginal delivery come out and clear the airways.

Posture, Behavior and Cry

A full-term infant maintains a posture of flexion, a result of the uterine position and a mechanism to conserve heat. Any deviation from this flexed posture should be noted. For example, a newborn who presented as breech would have a posture dependent on the presenting part (a frank breech presentation often has legs extended). Premature babies may be more limp than a term baby that is flexed Premature, hypoxic newborns or those exhibiting narcosis assume a posture of limp extension. A neonate exhibiting hypertonia(mad, arching back) may have a CNS disorder or be experiencing withdrawal from maternal drug abuse. Magnesium sulfate which is a CNS depressant ( for use of hypertension)= flaccid baby at birth

Eyes

A very slight drainage of the eyes may occur after eye prophylaxis; however, copious drainage is not normal. A persistent purulent drainage could be due to a blocked lacrimal duct or infection. The nurse should report the condition and obtain a culture as indicated. Note the neonate's eye shape. It should correspond to ethnicity. Deviations should be reported since a genetic abnormality such as Down syndrome may be possible.

Tongue

An excessively large tongue, tongue protrusion, or an abnormally small jaw should be reported since these observations can indicate genetic disorders. Tongue Protrusion Tongue Enlargement Abnormally Small Jaw Abnormally Small Jaw and Receding Chin

History: Apgar score

Assessed at the one-minute, five-minute and then 10 minute mark(if the infant shows any distressing signs) Apgar scores give an indication of the neonate's initial adjustment to extrauterine life 0- dead/ no activity 1- slow, irregular, HR below 100BPM, some flexion of extremities, Grimace, Body pink with blue extremities 2- good cry, HR above 100BPM, active motion, Vigorous cry, Pink *usually will loose a point or two for color looking at heart rate, tone, cry, and color 7-9 indicates they are transitioning appropriately to extrauterine life which is a good indication the baby is progressing well

Bowel sound

Bowel sounds are usually present shortly after birth. Absent or hyperdynamic (too frequent) bowel sounds with a distended abdomen are abnormal, indicating an obstruction or infection. Of course, these findings should be reported immediately. Round belly at birth Should not be flat, distended or tight looking especially in the presence of absent or hyperdynamic bowel sounds

Chest

Engorgement (enlargement) of breast tissue in both sexes is normal in the neonate and is caused by maternal hormones. Such enlargement of breast tissue is insignificant, but may cause the parents concern. Occasionally, as substance consisting of milky fluid may be secreted by the breasts. This fluid is commonly called "witch's milk" and is also caused by maternal hormones. Mothers should be taught not to massage the infant's breast or express fluid since such action may predispose the newborn to infection. In some infants, the tip of the sternum may be prominent and is of no consequence. measurements of the breast buds and genitalias can determine the gestational age of the neonate Occasionally, an accessory nipple may be found on the chest. These are usually lower and medial to the actual nipple. These accessory nipples may be found on only one side or on both sides of the body. They do not contain breast tissue and do not develop later in life. They may also be called supernumerary nipples. Prominent xiphoid (normal)

Jaundice

Every newborn is carefully assessed for jaundice, a yellow-tinge to the skin. The presence of jaundice may due to normal physiologic jaundice in the newborn which appears after the first 24 hours of life. If noted during the first 24 hours, it is most likely due to pathologic jaundice (most commonly caused by an incompatibility involving the maternal and fetal blood). In either case, jaundice must be recorded, reported and followed. The normal level of bilirubin in the blood is approximately 1-2 mg/dl during the neonatal period. Typically, as the bilirubin level rises, jaundice appears in a cephalocaudal direction in the newborn. Since the danger of kernicterus (which causes brain damage) is increased as the bilirubin level rises. When the bilirubin level reaches approximately 20 mg/dl in an AGA term baby, there is increased concern about kernicterus. Close monitoring of jaundice is essential. If the nurse is unsure if an area is jaundiced, it is often helpful to press the skin with a finger over a bony area (ex. forehead or nose) and observe the area before the color comes back. The sclera of the eyes may also evidence jaundice.

Fontanels

Fontanels are wide spaces of unossified membranous tissue at the junction of skull sutures. Usually, 2 fontanels can be palpated in the neonate: Anterior fontanel- will close 1-1.5 years on top of babys head towards the front Posterior fontanel- closes at 2 months back of babys head The anterior fontanel is diamond-shaped and is located at the junction of the frontal, sagittal and coronal sutures. The anterior fontanel is the larger of the fontanels and normally closes between 12 - 18 months. The anterior fontanel is normally flat to softly depressed but may bulge temporarily with crying. A tense, bulging fontanel is a symptom of increased intracranial pressure or infection (sepsis)- THINK SWELLING due to infection A sunken fontanel is an indication of dehydration- THINK SUNKEN EYES IN SOMEONE WHO IS DEHYDRATED Both conditions should be reported immediately. Should not be sunken down could indicate, hypokalemia?, FVD Should not be buldging could indicate increased ICP or sepsis

Forceps marks

Forceps marks: Pressure from forceps application during birth may result in red, circular marks over the face, especially anterior to the ears. When these marks are noted, the examiner should check carefully for any facial nerve paralysis or breaks in the skin. All breaks in the skin observed on assessment should be noted since they may serve as ports of entry for infection.

Head Circumference larger than normal

If the head circumference is larger than normal, the nurse could suspect the cause to be: 1. Hydrocephalus- Enlargement of the neonate's head due to an accumulation of cerebrospinal fluid in the cranial vault. Since the neonate's sutures are not yet fused, head expansion can occur. There are many causes of hydrocephalus. RARE *2. Caput succedaneum- PITTING EDEMA of the fetal scalp due to pressure during the birth process. This edema can cross suture lines. FLUID FILLED, mushy,spongy, and moveable NORMAL- fluid will be reabsorbed. An area of swelling or edema may form on the presenting part as a result of pressure during labor and delivery or through the use of a vacuum extractor. This swelling is called a caput succedaneum. A caput succedaneum is most pronounced at, or shortly after, birth. It is important to remember that, since edema is just under the skin, the area of involvement may cross suture lines. This fact helps differentiate a caput succedaneum from a cephalhematoma. The edematous area is soft and spongy with possible eccymosis. It will resolve spontaneously in a few days. *3. Cephalhematoma- A collection of blood in the space between the cranial bone and its covering (the periostium) due to pressure during the birth process. Due to it's location, a cephalhematoma CAN NOT CROSS SUTURE LINES!. BLOOD FILLED Baby will be more prone to develop jaundice, due to RBC hemolysis A cephalhematoma is a collection of blood in the subperiosteal space (between the periosteum and the skull bone). It is also caused by labor and delivery pressure; however, while a cephalhematoma may be evident in a few hours after birth, some may not be noted for a day or so after birth. The mass is soft, irreducible and fluctuating. Due to the location of the bleeding (between the skull bone and its covering), the area of involvement does not cross suture lines, with the most common area of involvement being over a parietal bone. The cephalhematoma usually resolves without treatment in several weeks. 4. Subdural hematoma- Bleeding from a venous source in the subdural space due to trauma, usually during the birth process. MORE SEVERE, bleeding into the brain, under the bone, usually due to traumatic births and use of foreceps RARE! Can only see on X-ray *babies bleed more easier than adults because they have no produced vitamin K

Head Circumference smaller than normal

If the head circumference is smaller than normal, the nurse could suspect the cause to be: 1. Molding ( one day the head could be 13inches and the next could be 14 inches- this is normal) 2. Microcephaly(small head) - An abnormally small cranium. This is a permanent birth defect due to an abnormally small brain. Microcephaly may be seen as a singular abnormality or as part of a syndrome, such as Alcohol Related Birth Defect (ARBD) which is often called Fetal Alcohol Syndrome 3. Premature closure of the sutures (craniosynostosis)- A birth defect where some of the sutures of the fetal skull prematurely close or fuse together. The premature closure of these sutures will result in an abnormally small head circumference and an abnormal shape of the neonatal head.

History

In beginning an assessment, the newborn's prenatal, maternal history and postnatal history must be considered. Since the newborn's condition may be influenced by this history, a nurse must be aware of such factors since they may indicate more detailed, more focused, or more extensive assessment measures. The history information and the rationale for obtaining such information is as follows: Obtaining this information gives a "ballpark" idea if the neonate is term, preterm or postterm. Since EDDs are not always reliable, other assessment data will be necessary for estimating gestational age. First think about gestational age! Is the baby term, preterm, postterm?

Genitourinary

In the term female, the labia majora covers the labia minora and clitoris. The labia may be enlarged due to a breech delivery. Skin color of the labia majora may be red or darkened due to the influence of maternal hormones. A mucoid discharge or pseudomenstruation (pink-tinged discharge) may be noted. Both are normal and due to maternal hormones. Smegma= a white cheesy substance, from oil gland secretion, may be found between the labia. Fecal discharge from the vagina is abnormal and may indicate a rectovaginal vistula. This should always be reported. The examiner will usually find a vaginal tag at the posterior of the labia minora. This structure will disappear within a few weeks. This is normal Observe the genitalia for appropriateness of sex. Ambiguous genitalia, whenever the sex is unclear by visual examination, should be reported immediately.

Hirshsprung's disease

Is also known as megacolon. A neonate with this disease is born with a segment of large intestine that lacks intact nerve ganglion. Since the nerve endings in the segment of bowel are not "connected", this segment of bowel does not move feces along the intestinal tract to achieve regular bowel movements. Children with Hirshsprung's disease usually have a history of delayed stooling as a newborn and chronic constipation. Since peristalsis is deficient in the affected segment, feces may distend areas of the bowel behind the defect. Resulting abdominal distension and gastrointestinal symptoms can also occur.

Auscultation of lungs

It is difficult to auscultate the neonate's chest due to the small size and cardiac and bowel sounds which are transmitted to the pleural cavity. To auscultate, use the small diaphragm or bell of the stethoscope and listen under the axilla as well as on the back. May here rhales, crackles, popping or wet lung sounds in the first few hours of life due to fluid in the lungs However, continued rales, rales accompanied by signs of respiratory distress or rhonchi are reported immediately. May have wet lung sounds within the first few hours of life which are normal

The heart

Like the respirations, the apical pulse should be counted for one full minute with the rate per minute normally being between 120 and 160 beats per minute. Of course, heart rate will also change with activity. Heart rate may vary depending on the delivery, if mom was pushing for a long time, maternal tachycardia, fetal tachycardia, etc.. If baseline was high before delivery expect around the same baseline, as with medications that can cause some mild fetal distress and bradycardia It is not unusual to note periods of irregular heart beat in the neonate in the first day or so of life, especially after episodes of crying. However, subsequent auscultation after a quiet period should follow such an observation. The apex of the heart is located for ausultation at the third or fourth intercostal space, lateral to the midclavicular line After 2 days the pediatrician may need to intervene if heart rate dosent return to normal

Skin

Linea nigra may be seen in some neonates. It is a darkened line extending from the umbilicus to the symphysis pubis. Usually linea nigra is seen in the neonates of mothers who have darker complexions and is caused by maternal hormones. Milia are tiny white spots appearing most frequently on the nose, chin, and forehead. They are due to clogged sebaceous glands and will disappear spontaneously. Mothers should be told about milia and warned not to squeeze them thinking they are "whiteheads." Vernix caseosa (or vernix) is a white, cheesy substance that may be evident on the newborn's skin, especially in body creases. It serves as a protective covering of the skin in utero and is removed with bathing over the first few days of life. Lanugo is fine, downy hair that first appears by the 20th week of gestation and begins to disappear as the fetus nears term. However, some lanugo may be noted on the term newborn, especially on the forehead, pinnas of the ears, cheeks, shoulders and back. Erythema toxicum is commonly called "newborn rash" and may appear as tiny "flea bites" or irregular erythematous macules often containing a central papule. This rash appears anywhere on the body except the palms and soles. No treatment is required as the rash will disappear spontaneously. Erythema toxicum will come and go for about the first 2 to 3 weeks of life.

Assessment of the head

Molding: Since the cranial sutures of the newborn are not yet "fused" together, overlapping of the skull bones may occur as the fetal head passes through the mother's pelvis. This altered contour of the head is called molding. In a vertex (occiput presenting) delivery, the forehead is often flattened with an apex ("point") forming at the end of the parietal bones. Usually molding will resolve spontaneously in a few days after birth.

Narcosis

Narcosis is a state resulting from high levels of opioid narcotics in the neonate's system. This state primarily results from injudicious use of opioid medications during labor, delivery of the neonate shortly after the mother receives an opioid medication or opioid narcotics in the newborn's system due to maternal drug abuse. The two major presenting symptoms of narcosis are respiratory depression and a posture of limp extension.

Natal teeth

Natal, or "rice", teeth are seen infrequently; however, they are precariously attached to the gingival margin which makes the risk of aspiration high. These should be reported so they can be removed as soon as possible.

Eyes

Neonates commonly keep their eyes closed and edema of the eyelids may be present from vaginal pressure at birth. Lasts a few days To facilitate opening the neonate's eyes, darken the room and hold the infant supine while gently lowering the head in a slight rocking motion. Eye color for light-skinned neonates is usually slate-blue to slate-gray. Dark-skinned newborns usually have brown eyes. The permanent eye color will be evident in 3 to 12 months.

Jitteryness/tremors

Newborns normally go through cycles of sleep and alertness. Deviations should be noted and reported. For example, excessive alertness or irritability are frequently signs of neurologic problems as is excessive drowsiness. A very irritable, active baby may also be evidencing withdrawal if the mother is a substance abuser (ex. Cocaine, heroin, or methamphetamine). "Jitteriness" or tremors may indicate hypoglycemia or hypocalcemia. CHECK BLOOD SUGAR! Cold stress The normal cry of a newborn is called "lusty" and vigorus A weak or shrill cry may indicate central nervous system problems and a grunting cry may indicate respiratory distress.

Stool

Note the number and color/type of the newborn's stools. A description of stools includes the amount (small, large, etc.), the color (yellow, yellow-green, etc.), and the type (seedy, mushy, watery, etc.). Diarrhea stools should be reported. If a neonate has not had a stool during an extended time, this information should be included in the report and on the chart.

Pulses

Palpate for femoral pulses, bilaterally, and note the quality (i.e. strong, weak, irregular, etc.). An absence or weakness of the femoral pulses may indicate a congenital heart defect called coarctation of the aorta. This defect involves a narrowing of the aorta which will, therefore, reduce the femoral pulses. Although this defect doesn't usually present immediately after birth, the nurse should still report femoral pulses that are not strong and regular. The beginning examiner of the newborn may find femoral pulses difficult to palpate. Care should be taken not to press on the area too firmly (this will press off the pulse). Fingers should be lightly placed on the pulse site in order to palpate effectively.

History: Mothers L&D Medications

Since certain analgesia (ex. Demerol) and anesthesia (ex. general or regional anesthesia) may affect the status of the newborn, this information should be known. Epidural anesthesia can also affect newborn and perfusion Example: If a mother received an opioid IV 15 minutes before delivery, the nurse would carefully assess the neonate for signs of respiratory depression. Consider Narcan if needed

Initial Assessment of the Lungs, Heart and Abdomen

Since many assessment measures may elicit crying in the newborn, it is best to begin with listening to the lungs, heart and abdomen and observing breathing while the neonate is still quiet. *Normal respiratory rate is 30 to 60 breaths per minute, and the examiner should count FOR 1 FULL MINUTE! Rationale: A newborn's respirations are normally quiet and shallow with short periods of apnea (less than 15 seconds). The newborn breathes diaphragmatically; therefore, it is easier to count abdominal rather than chest excursions. Want to look for symmetry and equal expansion in the diaphragm (best viewed by bending down at the bottom of the crib or examination table and looking toward the newborn's chest) Seeing seesaw or asymmetry is considered abnormal Could indicate a hernia or pneumothorax Diaphragmatic hernia - An opening in the diaphragm which creates an opening between the thoracic and abdominal cavities. This allows abdominal contents, such as loops of intestine, etc. to push into the thoracic cavity, displace the heart and create breathing difficulties for the neonate. The displaced structures will also alter the shape of the chest, resulting in asymmetry. Pneumothorax - Accumulation of air in the pleural space which prevents the lung tissue from expanding properly. The lay term for pneumothorax is "collapsed lung." Could be caused by difficult delivery or resuscitation measures (Positive pressure ventilation) *PPV tpiece now used to prevent this

Length Measurement

Since the newborn is usually in a flexed position, it is important to extend the leg completely when measuring length. The average length for a term newborn is 48 to 53 cm or 18 to 21 inches Note: Most paper tape measures have a blank space a couple of inches before the measurement marks begin - be sure to allow for this space when measuring the neonate( dont count this space)

Neck, chest and abdomen

Since the newborn's neck is short and wrinkled, it may be difficult to visualize. To facilitate assessment, support the infant's back in a slightly raised position and allow the head to gently fall back to extension. Observe any abnormalities in the range of motion, masses or webbing (multiple loose skin folds) and report any deviations. The clavicle is the most commonly fractured bone during delivery and may accompany a difficult delivery. Palpate the clavicles, noting any irregularity in shape or crepitance, and observe for any decreased movement of the shoulders or asymmetrical Moro reflex. Any deviations from normal are recorded and reported. Crepitance is the grating sound heard when two bone ends rub together when a bone is completely fractured. Since the clavicle of the newborn is a very small bone, the examiner may not hear crepitance, but rather feel the crepitance as a "chunchy" sensation when the area is palpated. Mcroberts maneuver is used which is the use of suprapubic pressure for shoulder dystocia in infants

Skin turgor

Skin turgor is an important assessment since neonates can become dehydrated quickly. If the neonate is well hydrated, the skin turgor will be supple when the skin is pinched between fingers. If the neonate is dehydrated, "tenting" will be noted when the skin is pinched between the fingers.

Skin tags

Small skin tags (preauricular tags) or "pits" (preauricular sinuses) located in front of the ear should be noted. They are usually a normal familiar variation; however, they can occasionally indicate a possible genetic disorder. Preauricular Sinus- dimple near, where the ear attaches to the skin Preauricular Tags- like channings :)

Epstein's pearls

Small white accumulations of epithelial cells frequently found on the palate or gums. They are insignificant and disappear within a few weeks; however, parents frequently notice them and may be concerned.

Male genitalia

Smegma is found under the foreskin on the glans penis and may be seen during a circumcision. The scrotum is frequently dark, large, pendulous, and edematous in the full-term neonate. The edema may be more pronounced if the newborn was born in a breech position. Tiny lines or wrinkles, called rugae, are noted on the scrotum of the term infant. The skin color of the scrotum is darkened due to the influence of maternal hormones. A normal variation occasionally noted are "pearls" (a collection of epithelial cells) on the tip of the penis

Assessing the eyes

Tears are occasionally present in the newborn, but are usually absent until the lacrimal ducts become patent in 2 - 3 months. Visualize the sclera of the eyes for color. The sclera should be white and clear; jaundice may be noted if the sclera has a yellow tint. The changes in vascular tension of the eye during birth may cause small areas of subconjunctival hemorrhage. These areas disappear spontaneously in 1 - 2 weeks but cause parents concern. Blue sclera = osteogenesis imperfecta, brittle bone disease, some are incompatible with life and some arent ranked in stages of severity 1-5 Subconjunctival hemorrhage- reddening of the sclera from pressure during birth usually resolve in a week or so

Birthmarks

Telangiectatic nevi, commonly called "stork bites", are hemangiomas (dilated capillaries) frequently found over the nape of the neck and eyelids. These hemangiomas are salmon-pink in color, blanch easily on pressure, may deepen in color with crying, and will eventually disappear spontaneously in a few years. Portwine stain (nevus flammeus) is not as common as teleangiectatic nevi. They are sharply delineated with no blanching with pressure. These areas are purple to red in Caucasians and black in dark-skinned babies. These birthmarks do not disappear. A strawberry hemangioma is raised, sharply demarcated and bright red in color. These are very vascular birthmarks, and they tend to shrink - and often disappear - with time.

Moro reflex

The Moro reflex is often called a startle reflex since sudden jarring of the crib or a change in equilibrium will elicit this reflex. Elicit this reflex by holding the neonate by his hands and lifting his shoulders up off the examining surface a couple of inches, then let go and allow the baby to fall back on the bed. The neonate responds to the sudden change in equilibrium by extending and abducting all extremities and fanning the fingers. This movement is followed by flexing and adducting the extremities as in an "embrace." This reflex is present, but less pronounced in a preterm baby. The Moro reflex begins to disappear about 3-4 months and is totally absent by 6 months.

Abdomen

The abdomen of the normal neonate is round and soft. Gentle palpation should be done to note any distension or abnormal masses (record and report). Abnormal distension may signify obstruction or infection. If an abnormal mass is palpated, report it immediately to the physician and do not palpate again until it has been investigated since the mass may be Wilm's tumor (handling a Wilm's tumor favors its metastasis). Sunken or scaphoid abdomen may be associated with diaphragmatic hernia, especially if bowel sounds are in the pleural cavity and the infant is in respiratory distress. A small abdominal girth or slightly sunken appearance may be associated with intrauterine growth restriction (IUGR). Diastasis (or separation) of the central abdominal muscles may occur in some newborns and is usually evidenced as an "out-pouching line" noted down the abdomen between the two linear muscles, especially when the infant cries. Although noted, this diastasis is usually of no consequence Newborn rash which is erythemia toxoicum- nothing to worry about just monitor

History: Length of time mothers membranes were ruptured before birth

The amniotic membrane serves as a barrier to infection. Rationale: The longer the membranes are ruptured before birth, the greater the chance for infection. On occasion, if the membranes have been ruptured for an extended period of time before birth (ex. 18 hours or greater ) with signs and symptoms of infection(maternal temperature, tachycardia, fetal tachycardia, high WBC) may need to do a sepsis workup which would include blood cultures and a CBC with differential may be done after delivery in newborn

The heart

The apex may be displaced by conditions as diaphragmatic hernia or pneumothorax and such displacement should be reported immediately. Dextrocardia is a condition where the heart is located on the right side of the chest. This, also, should be reported immediately so the physician can evaluate the neonate for functional circulatory abnormalities or organs which may also be abnormally reversed.

Back

The back and spine should be observed with the infant in the prone position. Abnormal curvature and any masses should be noted and reported. A protruding sac anywhere along the spine may indicate some type of spina bifida (i.e. myelomeningocele or meningocele). An indentation along the spine, especially when accompanied by a tuft of hair, may indicate spina bifida occulta. Spina bifida defects are often called "open spine defects" since the laminae of the vertebrae fails to close. With a myelomeningocele, the spinal cord and meninges protrude out of the body through the defect in the vertebrae and are enclosed in a sac covered by a thin membrane. With a meningocele, the meninges protrude out of the body through the defect in the vertebrae and are enclosed in a sac covered by a thin membrane. The spinal cord is intact. A spinal bifida occulta usually only involves a defect in the vertebrae. The meninges and the spinal cord are intact. The sacrococcygeal area should be observed for any evidence of a pilonidal "dimple" or sinus. If present, the site should be inspected for intactness since a sinus could be a portal of entry to the spinal column.

Chest circumfrence

The chest circumference is measured just above the nipple line, and the normal chest circumference is about 30 - 35 cm. or 12 - 14 inches. When compared to the head circumference, the chest circumference is usually 2-3 cm. (about 1 inch) less than the head circumference. *usually not performed unless other wise indicated that requires further assessment

Babinski reflex

The examiner strokes the infant's foot laterally from the heel up to the ball of the foot. The toes should hyperextend with a marked dorsiflexion ("fanning") of the big toe. This response is called a positive Babinski and is normal in the infant. One should note that this positive reflex will disappear after 1 year, and a positive Babinski is seen as pathological sign in an older child or an adult.

Extremities

The extremities of the newborn are examined for range of motion (gently), symmetry of movement, and any masses or malformations. Abnormal findings with regard to range of motion and symmetry could indicate fractures or nerve palsy (for example, Erb's palsy) and should be reported. Masses or malformations are also reported so that possible fractures or congenital anomalies may be investigated. While the clavicle is the most frequently fractured bone in the neonate, the humerus and femur rank next in frequency of occurrence. It is normal for the newborn to appear to have bowed legs. Flat feet are also a normal finding.

Feet

The feet are assessed for position. While the position in utero may cause the feet to appear slightly clubbed, the feet will easily move to the correct position with manipulation. True clubbing of the feet does not correct with positioning and should be reported.Skin

Ausculation of the heart

The first and second heart sounds (S1 and S2 or "lub-dub") should be clearly heard and well defined. Murmurs may be heard especially during the first few hours of life because of fetal circulation Frequently, they are due to incomplete closure of fetal shunts rather than a specific cardiac defect. Will hear the first few hours of life.. still will need to report/ document *Heart murmurs that persist with central cyanosis or equal pulses, need to assess blood pressure in all 4 extremeties to assess circulation and should be equal It is important for the nurse to remember that all murmurs are recorded, reported and followed by subsequent auscultation. Many nurses & physicians also assess the newborn's blood pressures in all 4 extremities whenever a murmur is heard to gain more assessment data needed for analysis. DONT normally take blood pressure in neonates, unless you hear a murmer, central cyanosis or not getting equal pulses *Murmers you will hear a background noise something like a whooshing sound

Head Circumfrence

The head circumference not only serves as a baseline to assess future growth, but it also may detect present abnormalities of growth. The head is measured placing the tape measure just above the eyebrows and continuing around over the most prominent part of the occiput. If molding has occurred during birth, a falsely low head head circumference will be obtained and the head should be measured when molding has disappeared. *cone head baby's may vary within hours may see an inch or so difference First inch on measurement on tape does not count Put around the largest part of the infants head right above the eyebrows 13.5-14 in normal size for infant Molding is when the fetal skull bones overlap in order to fit through the mother's pelvis during birth. This is possible since the fetal skull bones are not yet fused together. Molding will resolve in a few days after birth. The normal head circumference for a term neonate is 32 to 37 cm. or 12 ½ to 14 inches.

Mouth

The lips and palate should be visualized to note their intactness and absence of cleft lip or cleft palate. Symmetry of lip movement should be noted since asymmetry could signify nerve injury or nerve palsy. Sucking blisters may be noted on the central area of the upper lip and will look like a callous. Observing the neonate's cry is an excellent time to assess the mouth and to note any asymmetry of movement Note sucking blister on the central area of the upper lip which is nothing to worry about

History: Mothers blood type

The mother and baby's blood types may be incompatible and pathologic(something is wrong, more serious when mom is RH negative and in O+ moms)/physiological jaundice may occur. Since certain maternal blood types are more likely to lead to this problem, the nurse should especially note the maternal blood types of: 1. Rh negative (danger of Rh incompatibility) 2. O (danger of ABO incompatibility) Coombs test that looks for antibodies in the blood that may have been passed from the mother to the baby before birth, which will give an indication on if there will be a physiological jaundice In the above instances, the nurse should observe for any indication of early (within 24 hours) jaundice in the newborn. A Coombs test is also done on the cord blood. This test looks for the presence of antibodies formed by the mother and passed to the baby before birth. These antibodies cause the baby's RBCs to hemolyze, resulting in jaundice. LOOK AT YOUR MOM's LABS!!

Nails

The nails are observed for yellowing which may indicate meconium staining in utero. The fingers and toes should be inspected for number and intactness. Syndactyly, the fusion of digits, and polydactyly, one or more extra digits, are noted. Simian crease- transverse crease across the palm. Associated with downs

Weight

The newborn is weighed upon admission and once a day (preferably at the same time every day). 95% of all term newborns weigh between 2500 and 4200 grams (5 lbs. 8 oz. and 9 lbs. 6 oz.). Weight is recorded in both pounds/ounces and grams. Macrosomia is a large-for-gestational age baby Because of meconium and excessive extracellular fluid loss and the limited fluid intake, newborns usually lose 5 - 10% of their birth weight in the first 3 - 4 days; however, this weight should be regained by the 14th day. If this happens you may need to supplement breastfeeding with formula, or change formula An excessive amount of weight loss should be reported. It is normal for babies to loose weight in the first couple of days, babies always loose weight in the hospital. This is due to large BM, metabolic rate is high, intake is low at first and they are starting to pee. Babies should be weighed once a day(night) Small babies= smoking, drug abuse, hypertension, crappy placenta, anything that affects perfusion to baby

Reflexes

The newborn responds frequently with reflexes, some of which disappear with time. If a reflex is very weak or absent, the fact should be recorded and reported since neurological problems may be suspected. In the assessment, the examiner has already observed the sucking and rooting reflexes. Some life-long reflexes are termed protective reflexes. These protective reflexes are: blinking, sneezing, coughing, gagging and sneezing.

Voiding

The newborn should void within 24 hours after birth. If the infant has not voided or if the voiding is scanty, palpate the bladder for distension. Always report the fact that a newborn has not voided during the first 24 hours, has not voided during an extended time, or has a distended bladder. Uric acid crystals in the urine may cause "brick dust" stain on the diaper, and this should not be confused with blood. NORMAL and will decrease

Ears

The normal ear position in the newborn is determined as follows: -Draw an imaginary line from the inner to the outer cantus of the eye and back toward the ear. The line should intersect the ear close to its attachment to the scalp with the pinnae of the ear above that point. Abnormal positioning, especially low-set ears, should be reported since such positioning is frequently associated with kidney or chromosome anomalies (ex. Down syndrome) Intrauterine positioning may result in temporary asymmetry of the ears.

Anus

The normal neonate passes meconium within the first 24 hours of life and failure to do so should be reported. Patency of the anus (to check for patency of the anus) may be assessed by the insertion of a rectal thermometer. If patency of the anus is established and the infant still does not pass meconium in the first 24 hours, the pediatrician will investigate this problem. Obstruction, Hirshsprung's disease or a meconium plug due to cystic fibrosis are conditions which may be suspected if the neonate has not stooled after 24 hours. NO RECTAL TEMPERATURES Imperforate anus- no anus

Nose

The nose is normally flattened after birth and may be bruised or misshapened by intrauterine position May be temporary misshaped neonatal nose due to intrauterine position. Since newborns are nose breathers, nasal patency must be determined. One way to determine patency is to press off one nostril and note air passage through the unobstructed nostril. A newborn cannot breathe through his mouth, so this method works well to evaluate patency. An obstruction of nasal patency is called choanal atresia. Report any problems with nasal patency immediately. The nose may normally have some thin, white mucus drainage, but copious drainage is abnormal. A blood-tinged mucus discharge may be a sign of congenital syphillis

Male genitalia

The penis is inspected for the location of the urethral opening; however, the foreskin (prepuce) is almost always too tight to retract in order to view the urethral opening. An inability to retract the foreskin is not a sign of true phimosis in the newborn, and it will take several years until the foreskin is able to be retracted completely. Never force the foreskin to retract in order to observe the urethral opening but rather watch the infant void to determine placement (if possible). The placement of the urinary meatus is important to note so that hypospadias or epispadias may be detected early. Epispadias- is a defect of the penis when the urinary meatus opens on the top or dorsal side of the penis instead of midline Hypospadias- is a defect of the penis when the urinary meatus opens on the bottom side of the penis instead of midline. Whenever epispadias or hypospadias is present, the neonate's urinary stream will not have the typical "arc" normally seen and will often "dribble" urine down the penis.

Scalp

The scalp should be observed for any breaks in the skin (ex. a small break resulting from the EFM fetal scalp electrode). Hair should be silky and reflect ethnicity with the growth pattern toward the face and neck. A low-set hairline, unusual quality or quantity of hair or unusual swirls or patterns may indicate genetic disorder such as Trisomy 13

Male genitalia assessment

The scrotum should be palpated gently (warm hands, please) for the testes. One to two fingers of one hand are placed over the inguinal canal area while the fingers of the other hand palpate for the presence of bilateral testes. In preterm infants, the testes may still be within the inguinal canal. *if they have not dropped this is okay The scrotum of some infants will evidence a hydrocele which is a collection of fluid in the scrotal sac. A hydrocele will easily transilluminate. This should be recorded and reported, but most hydroceles resolve spontaneously within a year. The nurse may choose to check the cremasteric reflex in the newborn. A positive cremasteric reflex indicates integrity of the first lumbar nerve segment of the spinal cord. To illicit this reflex, stroke the anterior and inner thigh. The testicle on that side should retract.

Choanal atresia

This condition involves partial or complete blockage of a nasal passage. Although choanal atresia is usually unilateral, it can be bilateral. Of course, a bilateral and complete blockage would constitute a life-threatening emergency, and the neonate would require respiratory support until surgical correction of the defect is accomplished. If there is a unilateral blockage, the neonate will evidence cyanosis when the patent nostril is occluded.

Grasp reflex

This reflex is elicited by placing a finger in the palms of the newborn's hands or on the soles of the feet at the base of the toes. The neonate will flex the digits as if to "grasp" the examiner's finger. This reflex is also called the palmer grasp and the plantar grasp when elicited on the hands and feet, respectively. The palmer grasp reflex disappears as a reflex after about 3 months to be replaced by voluntary grasping action. The planter grasp reflex disappears at about 8 months. The nurse can use this reflex to facilitate bonding with the parents.

Skin

Throughout the assessment of the newborn, the nurse should observe the skin for various normal characteristics or deviations from normal. While deviations from normal should be recorded and reported, normal characteristics should also be mentally noted by the nurse since parents may not be cognizant of the "normality" and may have questions or concerns. The color of the skin will vary depending on race and ethnic group. In general, Caucasian newborns have pink to red skin color, black infants are pinkish-brown, and Asian neonates have a skin color described as "tea rose." Color may vary somewhat depending on activity - for example, becoming red with crying. Very pale skin color should be investigated and cyanosis, of course, requires immediate attention. Petechiae on the presenting part may represent a normal adaptation to the pressure of delivery. However, generalized petechiae or purpura over the body should be reported since this may indicate sepsis (infection) or an abnormality of platelet count.

Thrush

Thrush, caused by Candida albicans which may be present in the mother's vagina and transmitted to the newborn, may be noted in the mouth. The areas of thrush appear as white patches and resemble milk curds. To differentiate thrush from dried milk in the mouth, scrape with a tongue depressor. Dried milk will come off while thrush will leave small bleeding areas (so scrape gently). Report and record evidence of thrush to facilitate prompt treatment with a medication like Nystatin. Untreated thrush makes the baby's mouth sore, and he will not feed well.

Mouth reflexes

To elicit the sucking reflex, place a clean nipple or clean finger (index finger with the "pad" of the finger toward the palate) in the newborn's mouth. Note the strength of the sucking reflex. Also note any self-consoling sucking activity by the neonate. To elicit the rooting reflex, stroke the newborn's cheek near the mouth and observe the infant's response of turning toward the stimulated side. The sucking and rooting reflexes are strongest before feeding and, conversely, weakest after a feeding. Consistently weak sucking and rooting reflexes should be noted, however.

General measurements

When taking measurements (i.e. head and chest circumference and length), a non-stretchable (paper) tape measure should be used. Measure in both inches and centimeters. Measure above eyebrows First inch on measuring tape is not counted The neonate should be weighed without clothing. Weigh in both pounds + ounces or grams. Weigh the baby naked *About an hour after birth Weight should be equal to gestational age Keep them warm and dry Assess fetal heart rate by umbilical cord and let baby transition on mother EBP: let baby transition on mother (skin to skin) after drying and suctioning baby and monitor respiratory effort, assess pulse by umbilical cord, assign Apgar score and keep a close eye for the next hour on mom.

Symmetry of folds

While the neonate is still in the prone position, observe the symmetry of gluteal folds. Asymmetry of gluteal folds is reported to facilitate investigation of congenital hip dysplasia (note: hip dysplasia is a condition when the head of the femur does not securely fit into the acetabulum of the pelvis)