Maternal Newborn-Exam 4

Newborn assessment-pulse

Normal: 110-160 bpm Rate may increase (to 180 bpm) with crying and may decrease (to 90 bpm) when asleep. Murmurs may be heard, especially in the first 24 hours as shunts are closing; most are not pathological and disappear by 6 months. Abnormal: Tachycardia (>160 bpm) indicates possible sepsis, pain, respiratory distress, or congenital heart abnormality. Bradycardia (<100 bpm) indicates possible sepsis, increased intracranial pressure, or hypoxemia.

Newborn assessment-weight

Normal: 2,500-4,100 g (5.5 to 9.0 lb) Weight loss of 5%-10% of birth weight during the first week is normal. This is due to fluid loss through urine, stools, and lungs; and inadequate caloric and fluid intake the first days of life. The neonate will regain birth weight within 10-14 days. Abnormal: Weight above the 90th percentile is common in neonates of diabetic mothers. Weight below the 10th percentile may be due to prematurity, intrauterine growth restriction, or malnutrition during the pregnancy. Neonate should be evaluated for feeding problems if weight loss exceeds 7%.

Newborn assessment-respirations

Normal: 30-60 breaths per minute Unlabored Irregular with pauses up to 15 seconds (periodic breathing), with no color change Diaphragmatic and abdominal breathing Rate increases when crying and decreases when sleeping. Abnormal: Periods of apnea >20 seconds, especially if associated with color change. Tachypnea that may be related to sepsis, pain, hypothermia, hypoglycemia, or respiratory distress syndrome. Respirations <30; may be related to maternal analgesia or anesthesia during labor.

Newborn assessment-head circumference

Normal: 32-36 cm (12.5-14 in.) Abnormal: Microcephaly: Head circumference is below the 10th percentile of normal for newborn's gestational age. This is often related to congenital malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy. Macrocephaly: Head circumference is >90th percentile. This can be related to hydrocephalus

Newborn assessment-length

Normal: 46-52 cm (18-20.5 in.) Abnormal: Molding may interfere with accurate assessment of length. Neonates whose length is below the 10th percentile should be further assessed for causes such as intrauterine growth restriction or prematurity.

Newborn assessment-temperature

Normal: 97.7°F-99°F (36.5°C-37.2°C) Axillary Abnormal: Hypothermia or hyperthermia is related to infection, environmental extremes, or neurological disorders.

newborn assessment-musculoskeletal

Normal: Arms are symmetrical in length and equal in strength. Legs are symmetrical in length and equal in strength. 10 fingers and 10 toes. Full range of motion is observed of all extremities. No clicks at joints. Equal gluteal folds. C-shaped spine with no openings is felt or observed in vertebrae. No dimpling or sinuses are observed. Abnormal: Polydactyly: Extra digits may indicate a genetic disorder. Syndactyly: Webbed digits may indicate a genetic disorder. Unequal gluteal folds or positive Barlow and Ortolani maneuvers are associated with congenital hip dislocation. Decreased range of motion or muscle tone indicates possible birth injury, neurological disorder, or prematurity. Swelling, crepitus, or neck tenderness indicates possible broken clavicle, which can occur during the birthing process in neonates with large shoulders. Simian creases, short fingers, wide space between big toe and second toe are common with Down syndrome. Vertebrae openings may indicate spina bifida. Dimpling or sinuses may indicate pilonidal cyst or a more serious neurological disorder.

Newborn assessment-Posture

Normal: Extremities are flexed with symmetrical movements. Hands are clenched. Abnormal: Limp or floppy, or extension of extremities often related to prematurity; effects of medications given to mother during labor such as magnesium sulfate and analgesics or anesthesia; birth injuries; hypothermia; hypoglycemia; or hypoxia (late sign).

Newborn assessment-eyes

Normal: Eyes are equal and symmetrical in size and placement. The neonate is able to follow objects within 12 inches of the visual field. Edema may be present due to pressure during labor and birth or reaction to eye prophylaxes. The iris is blue-gray or brown. The sclera is white or bluish white. Subconjunctival hemorrhage may be present due to pressure during labor and birth. Pupils are equally reactive to light. Abnormal: Absent red-light reflex indicates cataracts. Unequal pupil reactions indicate neurological trauma. Blue sclera is a possible indication of osteogenesis imperfecta.

Newborn assessment-neurological

Normal: Flexed position Rapid recoil of extremities to the flexed position Positive newborn reflexes Abnormal: Hypotonia: Floppy, limp extremities indicate possible nerve injury related to birth, depression of CNS related to maternal medication received during labor or to fetal hypoxia during labor, prematurity, or spinal cord injury. Hypertonia: Tightly flexed arms and stiffly extended legs with quivering indicate possible drug withdrawal. Paralysis indicates possible birth trauma or spinal injury. Tremors are possibly due to hypoglycemia, drug withdrawal, or cold stress.

newborn assessment-female genitourinary

Normal: Labia majora covers the labia minora and clitoris. Labia majora and minora may be edematous. Blood-tinged vaginal discharge is related to the abrupt decrease of maternal hormones (pseudomenstruation). Whitish vaginal discharge is observed in response to maternal hormones. Urine may appear dark with urate crystals that appear as a red or rust-colored stain on the diaper ("brick dust"). This is normal the first few days of life. The neonate urinates within 24 hours. The urinary meatus is midline. Abnormal: Prominent clitoris and small, visible labia minora are often present in preterm neonates. Ambiguous genitalia; may require genetic testing to determine sex. No urination in 24 hours may indicate a possible urinary tract obstruction, polycystic disease, or renal failure.

Newborn assessment-mouth

Normal: Lips, gums, tongue, palate, and mucous membranes are pink, moist, and intact. Reflexes are positive. Dry lips are common after birth. Epstein's pearls are present Abnormal: Cyanotic or bluish mucous membranes are a sign of hypoxia. Dry mucous membranes are a sign of dehydration Natal teeth, which can be benign or related to congenital abnormality Thin philtrum may be indicative of fetal alcohol syndrome. Cleft lip or palate, which is a congenital abnormality in which the lip or palate does not completely fuse

Newborn assessment-head

Normal: Molding present Fontanels are open, soft, intact, and slightly depressed. They may bulge with crying. The anterior fontanel is diamond shaped, approximately 2.5-4 cm (closes by 18 months of age). The posterior fontanel is a triangle shape that is approximately 0.5-1 cm (closes between 2 and 4 months). May be difficult to palpate due to excessive molding. There are overriding sutures when there is increased molding. Abnormal: Fontanels that are firm and bulging and not related to crying are a possible indication of increased intracranial pressure. Depressed fontanels are a possible indication of dehydration. Bruising and laceration are observed at the site of the fetal scalp electrode or vacuum extractor. Presence of caput succedaneum or cephalohematoma is observed

Newborn assessment-cardiac

Normal: Point of maximal impulse (PMI) at the third or fourth intercostal space. S1 and S2 are present. Regular rhythm with some variability related to activity and respiratory changes. Murmurs in 30% of neonates, which disappear within 2 days of birth. Brachial and femoral pulses are present and equal. Abnormal: Dextrocardia: Heart on the right side of the chest. Displaced PMI occurs with cardiomegaly. Persistent murmurs indicate persistent or return to fetal circulation (opening of shunts with blood flow through them), or CHDs. Femoral pulses that feel weaker than brachial pulses may indicate a CHD.

Newborn assessment-skin/integumentary

Normal: Skin is pink and warm with acrocyanosis (cyanosis of hands and feet). Milia are present on the bridge of the nose and chin Lanugo is present on the back, shoulders, and forehead, which decreases with advancing gestation Peeling or cracking is often noted on infants >40 weeks' gestation. Slate gray patches (previously called Mongolian spots) Hemangiomas such as salmon-colored patch (stork bites), nevus flammeus (port-wine stain), and strawberry hemangiomas are developmental vascular abnormalities. Stork bites are found at the nape of the neck, on the eyelid, between the eyes, or on the upper lip. They deepen in color when the neonate cries. They disappear within the first year of life. Nevus flammeus are purple- to red-colored flat areas that can be located on various portions of the body. These do not disappear. Strawberry hemangiomas are raised bright red lesions that develop during the neonatal period. They spontaneously resolve during early childhood. Erythema toxicum, newborn rash Abnormal: Central cyanosis after the first 10 minutes of life is caused by reduced oxygen saturation and hypoxia. Circumoral cyanosis with pink mucous membranes may be benign. Jaundice within the first 24 hours is pathological Pallor occurs with anemia, hypothermia, shock, or sepsis. Greenish or yellowish vernix indicates passage of meconium during pregnancy or labor. Persistent ecchymosis or petechiae occurs with thrombocytopenia, sepsis, or congenital infection. Abundant lanugo is often seen in preterm neonates. Thin and translucent skin, and increased amounts of vernix caseosa, are common in preterm neonates. Nails are longer in neonates >40 weeks' gestation. Pilonidal dimple: A small pit or sinus in the sacral area at the top of the crease between the buttocks; the sinus can become infected later in life.

Newborn assessment-abdomen

Normal: The abdomen is soft, round, protuberant, and symmetrical. Bowel sounds are present but may be hypoactive for the first few days. Passage of meconium stool within 48 hours postbirth. The cord is opaque or whitish blue with two arteries and one vein, and covered with Wharton's jelly. Skin around the umbilical cord should be assessed for infection and have no redness, swelling, drainage, or foul smell. The cord becomes dry and darker in color within 24 hours postbirth and detaches from the body within 2 weeks. Abnormal: Asymmetrical abdomen indicates a possible abdominal mass. Hernias or diastasis recti are more common in Black neonates and usually resolve on their own within the first year. One umbilical artery and vein is associated with heart or kidney malformation. Failure to pass meconium stool is often associated with imperforated anus or meconium ileus.

newborn assessment-rectum

Normal: The anus is patent. Passage of stool within 24 hours. Abnormal: Imperforated anus requires immediate surgery. Anal fissures or fistulas may be present.

Newborn assessment-chest and lungs

Normal: The chest is barrel-shaped and symmetrical. Breast engorgement may be present in both male and female neonates related to maternal hormones and resolves within a few weeks. Clear or milky fluid from nipples related to maternal hormones. Lung sounds are clear and equal. Scattered crackles may be detected during the first few hours after birth. This is due to retained lung fluid, which will be absorbed through the lymphatics. Abnormal: Pectus excavatum (funnel chest) is a congenital abnormality. Pectus carinatum (pigeon chest) can obstruct respirations. Chest retractions are a sign of respiratory distress. Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, or prolonged periods of apnea (>15-20 seconds) are signs of respiratory distress. Decreased or absent breath sounds are often related to meconium aspiration or pneumothorax.

Newborn assessment-neck

Normal: The neck is short with skin folds. Positive tonic neck reflex may be present Abnormal: Webbing or large thick skin folds at the back of the neck is a possible indication of genetic disorders. Absent tonic neck reflex is an indication of nerve injury.

Newborn assessment-nose

Normal: The nose may be flattened or bruised related to the birth process. Nares should be patent. Small amount of mucus is present. Neonates primarily breathe through their noses. Abnormal: Large amounts of mucus drainage can lead to respiratory distress. A flat nasal bridge is seen with Down syndrome. Nasal flaring is a sign of respiratory distress.

newborn assessment-male genitourinary

Normal: The urinary meatus is at the tip of the penis. The scrotum is large, pendulous, and edematous with rugae (ridges or creases) present. Both testes are palpated in the scrotum. The neonate urinates within 24 hours with an uninterrupted stream. Urine may appear dark with urate crystals ("brick dust") that appear as a red, orange, pink, or rust-colored stain on the diaper. This is normal the first few days of life. Abnormal: Hypospadias: The urethral opening is on the ventral (under) surface of the penis. Epispadias: The urethral opening is on the dorsal (upper) side of the penis. Undescended testes (cryptorchidism): testes are not palpated in the scrotum. Hydrocele is enlarged scrotum due to excess fluid. No urination in 24 hours may indicate possible urinary tract obstruction, polycystic disease, or renal failure. Ambiguous genitalia may require genetic testing to determine sex. Inguinal hernia.

Newborn assessment-ears

Normal: Top of the pinna is aligned with the external canthus of the eye. Pinna is without deformities, well-formed and flexible. The neonate responds to noises with positive startle signs. Hearing becomes more acute as Eustachian tubes clear. Neonates respond more readily to high-pitched vocal sounds. Abnormal: Low-set ears are associated with genetic disorders such as Down syndrome. Absent startle reflex is associated with possible hearing loss. Skin tags, dimpling, or other lesions may be associated with kidney or other abnormalities.