Chapter 20: Assessment of the Normal Newborn

neonatal reflexes

1. Babinski 2. Gallant 3. grasp reflex (palmar and plantar) 4. moro reflex 5. rooting 6. stepping 7. sucking 8. swallowing 9. tonic neck reflex

swallowing

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

flaring of the nares

A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen.

ruddy color

A ruddy or reddish skin color (plethora) may indicate polycythemia, an excessive number of red blood cells (RBCs). Hct value above 65% confirms polycythemia. Infants with elevated Hct levels are at increased risk for jaundice from the normal destruction of excessive RBCs that occurs after birth.

eyes assessment

The eyes are examined for abnormalities and signs of inflammation. They 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 (Johnson, 2014). Slanting epicanthal folds in a 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 causes capillary rupture in the sclera. The edema diminishes in a few days, and the hemorrhages resolve in 7 to 10 days (Johnson, 2014). The sclera should be white or bluish white. A yellow color indicates jaundice. A blue color occurs in osteogenesis imperfecta, a congenital bone condition. Conjunctivitis may result from infection or a chemical reaction to medications. Staphylococcus, Chlamydia, and Neisseria gonorrhoeae are common organisms that cause infection. Maternal gonorrhea can cause infection of the infant during birth. The resulting ophthalmia 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 to 4 months after birth because infants have poor control of their eye muscles (Kaufman, Miller, & Gupta, 2015). 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 (Kaur & Campbell, 2016). Excessive tearing may indicate a plugged lacrimal duct, which is treated with massage or surgery. Visual acuity is approximately 20/400 (Olitsky et al., 2016). The eyes cannot accommodate well, but newborns should show a visual response to the environment. They should make eye contact when held in a cradle position during a period of alertness. Although they focus best on objects that are 20 to 30 cm (8 to 12 inches) away, they can see objects to a distance of 76 cm (2.5 feet) (Blackburn, 2013). They should respond well to human faces and geometric patterns of black and white or medium bright colors but show little interest in pastel colors. Newborns should blink or close their eyes in response to bright lights. Any infant who does not respond to visual stimuli should be reported to the physician or nurse practitioner for further investigation.

assessment of thermoregulation

The neonate's temperature is taken soon after birth while the infant is being held by the mother or in a radiant warmer with a skin probe attached to the abdomen. The probe, which should not be attached over bony prominences or areas of brown fat, allows the warmer to measure and display the infant's skin temperature continuously. The temperature control is set to regulate the amount of heat produced according to the infant's skin temperature. The temperature should be assessed at least once every 30 minutes until the infant has been stable for 2 hours after birth (AAP & ACOG, 2012). It is often checked again at 4 hours and then once every 8 to 12 hours or according to facility policy as long as it remains stable (see Procedure 20.1). The most common method of taking the neonate's temperature is axillary measurement (Fig. 20.2). The normal range for axillary temperature is 36.5° to 37.5°C (97.7° to 99.5°F) (Gardner & Hernandez, 2016a) (Box 20.1). Taking axillary temperatures is safer than taking rectal temperatures because it avoids the possibility of irritation or injury to the rectum, which turns at a right angle approximately 3 cm (1.2 inches) from the anal sphincter (Gardner & Hernandez, 2016b). The location always should be charted along with the temperature measurement. If a rectal temperature is necessary, the nurse should use great caution because inserting the thermometer too far could cause potentially fatal perforation of the intestinal wall. A thermometer should never be forced into the rectum because of the possible presence of an imperforate (closed) anus.

genitalia

The nurse examines the newborn's genitalia for size, maturation, and presence of any abnormalities.

GU system assessment

consists of assessment of: 1. kidney palpation 2. urine 3. genitalia

GI system assessment

consists of assessment of: 1. mouth 2. suck reflex 3. initial feeding 4. abdomen 5. stools

sensory assessment

consists of assessment of: 1. ears 2. eyes 3. sense of smell and taste

hips

1. The hips are 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. 2. 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 the prone position to determine whether they are equal in length and if the thigh and gluteal creases are symmetric (Fig. 20.7). If the hip is dislocated, the leg on the affected side is shorter and the creases are asymmetric. Because the hip may be unstable but not yet dislocated, these signs may not be present at birth. 3. Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period (Fig. 20.8). These maneuvers are performed by the physician or advanced practice nurse. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the "clunk" of hip dysplasia when the femoral head moves in the hip socket (Schwend, Shaw, & Segal, 2014). 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.

male genitalia assessment

1. The scrotum should be pendulous at term and may be dark brown from maternal hormones. Pressure during a breech delivery may cause it to be edematous. Rugae (creases in the scrotum) are deep and cover the entire scrotum in the full-term infant. 2. 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 later surgery. Palpation of the scrotum determines whether the testes have descended (Fig. 20.12). 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 one with testes. Undescended testes (cryptorchidism) occurs on one or both sides. Approximately 50% to 70% of undescended testes in full-term infants will descend within 3 months. If the testes do not descend within 12 months, surgery is performed to preserve fertility (North & Gearhart, 2016). 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. Parents are very concerned about any abnormalities of the genitalia. 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.

hepatic assessment

1. blood glucose 2. bilirubin conjugation

ongoing assessment

1. breathing 2. activity 3. color 4. Hx of pregnancy

early focussed assessments

1. cardiorespiratory status 2. muscle tone 3. thermoregulation 4. estimation of the gestational age 5. presence of anomalies. 5. The nurse determines whether resuscitation or other immediate interventions are necessary. 6. If no anomalies are present, the nurse should facilitate parent-infant attachment and initiation of breastfeeding while continuing ongoing assessments. of breathing, activity, and color. 7. Completion of a more thorough admission assessment follows. 8. If possible, this assessment should be performed in the mother's room to provide an opportunity for parent teaching and continued parent-infant attachment.

components of skin assessment

1. color 2. mottling 3. vernix caseosa 4. lanugo 5. milia 6. erythema toxicum 7. birthmarks 8. marks from delivery

assessment of physical characteristics of skin

1. color 2. visibility of veins 3. peeling 4. cracking 5. The very preterm infant's skin is translucent because it is thin and has little subcutaneous fat beneath the surface. 6. The skin is red, sticky, and fragile, with easily visible veins. 7. In the mature newborn, the skin is thicker and the color is paler. Few veins are visible, usually over the chest and abdomen. 8. At term, vernix is present only in the creases. 9. The full-term infant exhibits some peeling and cracking of the skin, especially around areas with creases, such as the ankles and feet. The postmature infant has deeply cracked skin that appears as dry and thick as leather. Peeling becomes even more apparent during the hours after birth as the skin loses moisture.

expected response to painful stimuli

1. crying 2. increase in vital signs.

color assessment

1. cyanosis 2. pallor 3. ruddiness

components of general assessment

1. head 2. molding 3. fontanels 4. caput succedaneum 5. cephalohematoma 6. face

assessment of male genitals in the newborn

1. location of the testes 2. rugae on the scrotum 3. testes originate in the abdominal cavity and begin to descend at 28 weeks of gestation. 4. By 37 weeks of gestation, they are located high in the scrotal sac, and they are generally completely descended by term. 5. Rugae cover the surface of the scrotum by 40 weeks of gestation. 6. Once the testes are completely down into the scrotum, the scrotum appears large and pendulous.

components of heart sounds assessment

1. position 2. rhythm & murmurs

airway assessment

1. respiratory rate 2. breath sounds 3. signs of respiratory distress

rhythm and murmurs in newborn heart

1. rhythm should be regular, and the first and second sounds should be heard clearly. 2. Abnormalities in rhythm and sounds such as murmurs should be noted. 2. A murmur is common until the ductus arteriosus is functionally closed. 3. 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.

signs of respiratory distress

1. tachypnea 2. retraction 3. flaring of the nares 4. cyanosis 5. grunting 6. seesaw or paradoxical respirations 7. asymmetry

other neurologic signs

1. tremors or jitteriness. 2.. seizures 3. shrill, high pitched, hoarse or cat-like mewing cry 4. Excessive irritability (injury to CNS)

measurements of the newborn

1. weight 2. length 3. head circumference 4. chest circumference

documentation of skin assessment

All marks, bruises, rashes, and other abnormalities of the skin must be recorded in the nurses' notes. The location, size, color, elevation, and texture of each mark are described. Subsequent changes in appearance from previous descriptions also are noted on the chart. The nurse may not always know the proper name for each type of mark on the infant's skin. Most agencies have books with pictures of the common skin variations. When in doubt about the name of a mark, a description is sufficient. For example, a nevus simplex (stork bite) might be described as a "flat, pink area 1 × 2 cm in size over nape of the neck that blanches with pressure."

assessment scoring

As each part of the gestational age assessment is performed, the infant's 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 two characteristics alone are not enough to assign a gestational age. It is the total score of all assessed characteristics that determines the gestational age. A difference of 2.5 points is necessary to change the gestational 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.

reflexes assessment

Assessment of the reflexes is important to determine the health of the newborn's CNS. The nurse notes the presence and strength of the reflexes and whether both sides of the body respond symmetrically (Fig. 20.9). A diminished overall response occurs in preterm and ill infants. Absence of reflexes may indicate a serious neurologic 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 (Table 20.1).

grunting

Grunting describes a noise made on expiration when air crosses partially closed vocal cords. This increases the pressure within the alveoli, which keeps the alveoli open and enhances the exchange of gases in the lungs. Grunting may be very mild and heard only with a stethoscope or loud enough to be heard unaided in an infant having severe respiratory difficulty. Persistent grunting is a common sign of respiratory distress syndrome and necessitates expanded assessment and referral for treatment.

Harlequin color change

Harlequin coloration is 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.

assessment of female genitals in the newborn

In the female infant, the relationship in size of the clitoris, labia minora, and labia majora is noted (Fig. 20.29). In the preterm infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. As the infant nears term, the labia majora enlarge until the clitoris and labia minora are completely covered. Because 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.

female genitalia assessment

In the full-term female infant, the labia majora should be large and completely cover the clitoris and labia minora. The labia may be darker than the surrounding skin, a normal response to exposure to the mother's hormones before birth. Edema of the labia and white mucous vaginal discharge are normal. A small amount of vaginal bleeding, known as pseudomenstruation, may occur from the sudden withdrawal of the mother's hormones at birth. Hymenal (vaginal) tags are small pieces of tissue at the vaginal orifice. These are normal and disappear in a few weeks. The urinary meatus and vagina should be present.

assessment for lanugo

Lanugo appears at 20 weeks of gestation and increases in amount until 28 weeks (see Fig. 20.13), when it begins to disappear. Most is shed by 32 to 36 weeks (Gardner & Hernandez, 2016b). 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.

urine

Most newborns void within 12 to 24 hours of birth and a few within 48 hours of birth. Because absence of urine output during this time may indicate anomalies, the first void should be carefully noted 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. Because of the small amount, the first void may be missed. Sometimes it occurs at birth but goes unnoticed because attention is focused on the infant's overall condition. If there is a concern about whether 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 if she has changed a wet diaper. Increasing the infant's fluid intake often can initiate urination. If no void occurs in the expected time, the infant's fluid intake should be increased and the physician or nurse practitioner alerted. By the fourth day of life, at least six wet diapers can be expected daily. Each void is recorded in the infant's 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 six wet diapers by the fourth day indicates the infant is taking adequate fluid. If an infant is having feeding difficulties, noting the number of wet diapers is especially important. Disposable diapers are very absorbent, and the pale color of the newborn's 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 newborn's urine may contain uric acid crystals that cause a reddish or 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.

pallor

Pallor can indicate that the infant is slightly hypoxic or anemic. A laboratory examination of hemoglobin (Hgb) and hematocrit (Hct) or a complete blood count may be ordered.

kidney palpation

Palpation of the kidneys is not usually performed as part of the routine nursing assessment. The health care provider palpates the kidneys just above the level of the umbilicus on each side of the abdomen during the first hours after birth. Abdominal masses may indicate enlargement or tumors of the kidneys. Kidney anomalies may accompany other defects because a problem early in fetal development may affect several organs vulnerable at that time. For example, 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 whether the kidneys are functioning adequately.

assessment of plantar surface

Plantar creases begin to appear at 28 to 32 weeks of gestation and cover the entire foot by term (Trotter, 2014) (Fig. 20.26). 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 creases appear more prominent as the infant's skin begins to dry. For the very preterm infant, the length of the foot is measured to help determine gestational age.

risk factors for neonatal hypoglycemia

Prematurity Postmaturity Late preterm infant Intrauterine growth restriction Large or small for gestational age Asphyxia Problems at birth Cold stress Maternal diabetes Maternal intake of terbutaline

seizures

Seizures indicate CNS 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 also may 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.

tachypnea in the newborn as a sign of respiratory distress

Tachypnea, a respiratory rate of more than 60 breaths per minute, is the most common sign of respiratory distress. It is not unusual during the first hour after birth and during the periods of reactivity, but continued tachypnea is abnormal.

temperatures

Temperatures are usually measured with an electronic digital thermometer. Inexpensive digital thermometers used while the infant is in the hospital are often given to the parents for home use. Tympanic thermometers, used in some facilities for older infants and children, are not recommended for newborns (Gardner & Hernandez, 2016b). Some agencies use temporal artery thermometers.

New Ballard Score

The New Ballard Score (Fig. 20.19) is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of birth (Benjamin & Furdon, 2015). A score is given to each assessment, and the total score is used to determine the gestational age of the infant. The New Ballard Score is described in the following section.

heart 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 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 (a right-to-left reversal from the normal heart position).

gestational age and infant size

The appropriateness of the neonate's size for gestational age is determined by plotting the weight, length, head circumference, and gestational 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 gestational age falls between the 10th and 90th percentiles on the graph. The large-for-gestational-age (LGA) infant is above the 90th percentile, and the small-for-gestational-age (SGA) infant is below the 10th percentile.

head and chest circumference

The diameter of the head is measured around the occiput just above the eyebrows. The normal range of head circumference for the term newborn is 32 to 38 cm (13 to 15 inches) (Benjamin & Furdon, 2015). The measurement may be affected by molding of the skull 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 usually is 2 to 3 cm smaller than the head. The normal circumference of the chest is 30 to 36 cm (12 to 14 inches) (Vargo, 2014b). If molding of the head is present, the head and chest measurements may be equal at birth.

ears assessment

The ears are 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 (Fig. 20.10). Low-set ears may indicate chromosomal abnormalities. The ears should be almost vertical in placement on the head. The nurse examines the ears for skin tags and preauricular sinuses and dimples. If they occur with any other abnormalities, renal ultrasound is often performed (Kaur & Campbell, 2016). Abnormalities of the ear may indicate chromosomal abnormalities, hearing problems, or kidney defects. The stiffness of the cartilage and degree of incurving of the pinna are checked as part of the gestational age assessment. Hearing begins to develop by 23 to 24 weeks of gestation (Blackburn, 2013). Infants can hear by the last trimester of pregnancy, and their hearing is very good after birth. Hearing is assessed by noting the infant's 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.

assessment of physical characteristics of eyes and ears

The eyelids are fused until 26 to 28 weeks of gestation (Trotter, 2014). When the ear is assessed, the incurving and thickness of each pinna are rated (Fig. 20.28). 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 because of 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 ear returns to its original state. In newborns less than 34 weeks of gestation, 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.

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, two 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 a simian crease or line. It may be seen with incurving of the little finger in Down's syndrome (trisomy 21). The simian line alone is not diagnostic of trisomy 21, however, and may occur in 5% to 10% of normal infants (Kaur & Campbell, 2016). The feet are assessed for talipes equinovarus, or clubfoot, 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 probably temporary, resulting from the position of the infant in the uterus. In true clubfoot, the foot turns inward and cannot be moved to a midline position. Casting and manipulation are the usual treatment, but in some cases surgery is necessary.

assessment of gestational age

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

heart sounds assessment

The heart is auscultated for rate, rhythm, and the presence of murmurs or abnormal sounds. The nurse should count the apical heart rate for a full minute for accuracy and listen for abnormalities. The rate should range between 120 and 160 beats per minute (bpm) with normal activity. It may elevate to 180 bpm when infants are crying or drop to as low as 100 bpm when they are in deep sleep. If there are no problems present at birth, the heart rate should be recorded at least once every 30 minutes until the infant has been stable for 2 hours after birth (AAP & ACOG, 2012). Monitoring is more frequent if abnormalities are present. Once stable, the heart rate is checked once every 8 to 12 hours or according to hospital policy unless a reason for more frequent assessment develops.

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 neurologic injury. Infants with previously good muscle tone may show decreased flexion if they become hypoglycemic or experience respiratory difficulty. All extremities 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 (Erb-Duchenne paralysis), paralysis of the shoulder and arm muscles. Instead of the usual flexed position, the affected arm is extended at the infant's 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 assessment

The infant's 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 to 53 cm (19 to 21 inches) (Cheffer & Rannalli, 2015). Some agencies also record the crown-to-rump measurement, which is approximately equal to the head circumference.

skin assessment

The newborn's skin is fragile and shows marks easily, especially in infants with fair coloring. Because the skin is so sensitive, reddened areas and rashes may develop during the early days of life. The nurse should examine every inch of 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 and need emotional support.

assessment of physical characteristics of breasts

The nipples, areolae, and size of the breast buds are assessed 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 (Fig. 20.27). Use of the thumb and forefinger may cause excess tissue to be drawn together, resulting in an inaccurate score.

bilirubin

The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow 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 (Pan & Rivas, 2016). 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 or nurse practitioner may order laboratory determinations of the bilirubin level based on the nurse's assessment. In many facilities, protocols allow the nurse to obtain transcutaneous bilirubin (TcB) measurements using a bilirubinometer or laboratory measurement of total serum bilirubin (TSB) before notification of a nurse practitioner or physician. A bilirubinometer is a noninvasive device to measure bilirubin in the infant's skin, thus avoiding repeated skin punctures to obtain blood samples. Obtain TSB or 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 infant's 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. The AAP and ACOG (2012) recommend obtaining TSB or TcB measurements on every infant before discharge. This helps determine whether discharge should be delayed or early follow-up arranged. All abnormal results should be documented and reported to the nurse practitioner or physician. Application of the nursing process in the care of infants at risk for hyperbilirubinemia is covered in Chapter 21, and a discussion of phototherapy is in Chapter 24.

neck and clavicles

The nurse assesses the infant's neck visually and notes the ease and extent with which the head turns from side to side. The neck should have full range of motion. It is very short. Webbing or 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, especially when shoulder dystocia occurred. Sliding the fingers along each clavicle while moving the infant's arm helps identify a fractured clavicle. If a fracture is present, a lump, 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 especially 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 (Fig. 20.6).

blood glucose assessment

The nurse must be alert for newborns at increased risk for hypoglycemia, which can cause brain damage. Factors that might have caused the infant to deplete available glucose are noted (Box 20.2). A quick estimate to determine whether the newborn appears to be near term and of appropriate size for gestational age is performed at birth. Observing for signs of hypoglycemia is necessary throughout routine assessment and care. Early signs include jitteriness and other CNS signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. Some infants with hypoglycemia show no signs at all. 2. Screening for blood glucose is not necessary for normal term infants (AAP & ACOG, 2012; Bloomfield, Dinolfo, & Kokotos, 2016). 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 to 60 mg/dL and 50 to 90 mg/dL thereafter (Lo, 2016). Because capillary blood is used in screening tests, these tests are less accurate than laboratory tests using venous blood. Therefore a laboratory analysis (per agency policy) should be used to verify readings of 40 to 45 mg/dL or below. 3. Avoiding injuries to the infant's foot is important when taking blood from the heel (Procedure 20.3). If the lancet goes into the calcaneus bone, osteomyelitis may result. Commercial devices for heel puncture are designed to puncture the heel to the proper depth. They are available for 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 40 to 45 mg/dL or less to prevent a further decrease in glucose, especially if the infant shows signs of hypoglycemia. The blood glucose is rechecked 30 to 60 minutes after the feeding and again before feedings until the results are acceptable or according to hospital policy. Infants who are in risk categories are usually monitored for 12 to 24 hours after birth (AAP & ACOG, 2012).

vertebral column assessment

The nurse palpates the entire length of the newborn's vertebral column to discover any defects in the vertebrae. An indentation is a sign of spina bifida occulta (failure of a vertebra 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 a meningocele (protrusion of spinal fluid and meninges) or a 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 the meninges. The tissue should be 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.

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.

abnormal pitch of cry

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 people 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.

umbilical cord

The umbilical cord should contain three vessels. The two 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 associated 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.

weight assessment

The weight of the term newborn ranges between 2500 and 4000 grams (g) (5 pounds [lb], 8 ounces [oz] and 8 lb, 13 oz) (Cheffer & Rannalli, 2015). If the infant's 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, hypertension, 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 (Feigelman, 2015). 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 approximately 30 g per day during the early months (Feigelman, 2016).

neuromuscular characteristics assessment

consists of assessment of: 1. posture 2. square window 3. arm recoil 4. popliteal angle 5. scarf sign 6. heel to ear

neurologic system assessment

consists of assessment of: 1. reflexes 2. sensory assessment 3. other neurologic signs

physical characteristics assessment

consists of assessment of: 1. skin 2. lanugo 3. plantar surface 4. breasts 5. eyes and ears 6. genitals

integumentary system assessment

consists of: 1. skin assessment 2. breast assessment 3. hair and nails

Babinski reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

Moro reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

grasp reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

rooting reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

stepping reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

sucking reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

tonic neck reflex

method of testing: expected response: abnormal response and possible cause: time reflex disappears:

Gallant reflex

trunk incurvation method of testing: expected response: abnormal response and possible cause: time reflex disappears: