ATI Book: Newborn Assessment

Complications: Airway Obstruction r/t Mucus: - What are some Nursing Considerations to prevent this?

- Mouth and nose are suctioned with a bulb syringe. Gentle precussion over the chest can help loosen secretions

Physical Exam From Head to Toe: - Skin: Significant Alteration that need to be reported: 1. What should be reported regarding to skin color? 2. What should be reported regarding signs of trauma? 3. What two Nevus should be reported?

1 Colors: Rudy, plethora, pallor / grey, central cyanosis, jaundice in first 24hrs or mod to severe jaundice after 24 hrs 2. Trauma: edema, bruises, petechiae, forceps marks, fetal scalp monitoring abrasion 3. Nevus Fammeus (port wine stain) and Nevus Vasculous (strawberry mark)

Vital Signs for Newborns: 1. Normal HR ranges? 2. What might affect the ranges? 3. How do we assess HR?

1. 110-160 BPM with average of 120 2. Activity level such as crying and sleeping can alter the HR range. 3. Apical pulse rate is assessed for 1 full minute, preferably when the newborn is sleeping. Place pediatric stethoscope head over 4th or 5th ICS LML over the apex of the newborns heart.

Physical Exam From Head to Toe: - Head: 1. Head should be __ to ___ cm _____ than the chest circumference 2. What if the head is greater than or equal to 4 cm larger than chest circumference? 3. What if the head is less than or equal to 32 cm?

1. 2 to 3 cm larger than chest circumference 2. If head is greater than or equal to 4 cm larger than chest circumference, it can be indication of hydrocephalus which is excessive cerebral fluid within the brain cavity surrounding the brain. 3. If head is less than or equal to 32 cm, this can be an indication of Microcephaly which is an abnormally small head

Classification after physical assessment, classification of newborn by gestational age and birth weight is determined: 1. Appropriate for Gestational Age (AGA) 2. Small for Gestational Age (SGA)? - What does SGA inc risk of? 3. Large for Gestational Age (LGA) - What does LGA inc risk of? 4. Low Birth Weight (LBW)

1. AGA: Weight is between 10th and 90th percentile 2. SGA: Weight is less than the 10th percentile. Under 2,500 g - Inc risk of hypoglycemia, thermoregulation and respiratory problems 3. LGA: Weight is greater than the 90th percentile. Over 4,000 g - Inc risk of hypoglycemia and birth traumas 4. LBW: Weight of 2,500 g or less at birth

Physical Exam From Head to Toe: - Head: 1. Anterior fontanel should be approx _____ cm and ___ shaped. 2. Posterior fontanel is ____ and ____ shaped. 3. Fontanels should be ____ and ____. Fontanels can ____ when a newborn ____, ____, or _______ and are ____ when the newborn is ______. 4. ______ fontanels can indicate ______, _____, or _____. 5. Sutures should be _________, _______, and can be ________ which is a normal occurrence resulting from ______

1. Anterior fontanel should be approx 5 cm and diamond shaped 2. Posterior fontanel should be smaller and triangle shaped. 3. Fontanels should be soft and flat. Fontanels can bulge when the newborn cries, coughs, or vomits, and are flat when the newborn is quiet. 4. Bulging fontanels can indicate increased ICP, infection, or hemorrhage 5. Sutures should be palpable, separated, and can be overlapping (molding) which is a normal occurrence resulting from head compression during labor

Physical Exam From Head to Toe: - Anogenital: 1. Anus should be _____, ____, and not _______ 2. Meconium should be passed within _____ to _____ hr after birth 3. Genitalia of a male newborn should include ____ on the _____ 4. Testes should be ______ 5. Male urinary meatus is located at the _____

1. Anus should be present, patent, and not covered by a membrane 2. Meconium should be passed within 24-48 hrs after birth 3. Genitalia of a male newborn should include rugae on the scrotum 4. Testes should be present in the scrotum 5. Male urinary meatus is located at the penile tip mid line

Physical Assessment of Newborn Following Birth: 1. What is done within the first minute and again at 5 minutes immediately after birth? 2. What are the 5 categories this measures? What would indicate a 0, 1, or a 2? 3. Explain the scoring process and what ranges would indicate: Severe distress, Moderate Difficulty, and Minimal or no difficulty with adjusting to extra-uterine life

1. Apgar Scoring and a brief physical exam 2. 5 Categories of Apgar: - Heart Rate: 0=Absent, 1=Slow, less than 100, 2=Greater than 100/min - RR: 0=Absent, 1=Slow, weak cry, 2=Good cry - Muscle Tone: 0=Flaccid, 1=Some flexion of extremities, 2=Well-flexed - Reflex Irritability: 0=None, 1=Grimace, 2=Cry - Color: 0=Blue/Pale, 1=Pink body, cyanotic hands and feet (acrocyanosis), 3=Completely Pink 3. Scored on 5 categories from 0-3. - Severe Distress: 0-3 Total Score - Moderate Difficulty: 4-6 Total Score - Minimal or No Difficulty with adjusting to extra-uterine life: 7-10 Total Score

Physical Exam From Head to Toe: - Extremities: 1. Assess for ____, _____ of motion, and ______ movements 2. Extremities should be _______ 3. Assess for _____ legs and _____ feet, which should be present because _________ muscles and more developed than the ______ muscles 4. No ___ should be heard when abducting the _____ 5. ________ folds should be ________ 6. Soles should be ______ over ______ of the feet 7. Nail beds should be ____ and no extra ____ are present

1. Asses for full range, symmetry of motion and spontaneous movements 2. Extremities should be flexed 3. Assess for bowed legs and flat feet, which should be present because lateral muscles are more developed than the medial muscles 4. No click should be heard when abducting the hips 5. Gluteal folds should be symmetrical 6. Soles should be well-lined over two-thirds of the feet 7. Nail beds should be pink with no extra digits

Physical Exam From Head to Toe: - Eyes: 1. Assess the eyes for _____ in _____ and ______ 2. Each eye and the space between the eyes should equal _____ the distance from the inner to the outer canthus of both eyes to rule out ____________, such as _______ 3. Eyes are usually ____ or ___ in color following birth 4. _____ are immature with minimal or no ______ 5. What can result from pressure during birth? 6. _____ and _______ reflex present at birth 7. Eyeball movements will demonstrate ____, ______ movements

1. Assess eyes for symmetry in size and shape 2. Each eye and the space btwn the eyes should equal 1/3rd the distance from the inner to the outer canthus of both eyes to rule out chromosomal abnormalities such as Down Syndrome. 3. Eyes are usually gray or blue at birth 4. Lacrimal glands are immature, with minimal or no tears 5. Subconjunctival hemorrhages can result from pressure during birth 6. Pupillary and red reflex are present 7. Eyeball movement will demonstrate random, jerky movements

Physical Exam From Head to Toe: - Mouth: 1. Assess for ______ and strength of _____ 2. Lip movements should be ______ 3. Saliva should be _____. Excessive saliva can indicate a ________ _______ 4. What are Epstein's Pearls and what causes them? 5. Tongue should _______, be ____ in shape and not ______, as this may be a sign of ________ 6. _______ and _______ should be intact 7. Gums and tongue should be ______. 8. What do gray-white patches on the tongue and gums indicate? 9. What is a typical normal variation?

1. Assess for palate closure and strength of sucking 2. Lips movements should be symmetrical 3. Saliva should be scant. Excessive saliva can indicate a tracheoesophageal fistula 4. Epstein's Pearls: Small white cysts found on the gums and at the junction of the soft and hard palates, are expected findings. They result from the accumulation of epithelial cells and disappear a few weeks after birth. 5. Tongue should move freely, be symmetrical in shape, and not protrude. A protruding tongue can be a sign of Down Syndrome 6. Soft and hard palate should be intact 7. Gums and tongue should be pink 8. Gray-white patches indicate thrush, caused by candida albicans sometimes acquired from the mothers vaginal secretions 9. Precocious tooth

Physical Exam From Head to Toe: Face: - What are 3 Common abnormalities to report?

1. Asymmetry 2. Drooping of one side of face 3. Note swelling / bruising trauma

Equipment For Newborn Assessment: 1. What is the Bulb Syringe used for? 2. What do we use to evaluate HR, breath sounds and bowel sounds? 3. What device do we use to measure temperature? What is avoided? 4. What size blood pressure cuff do we use? 5. How do we measure the newborn? Head circum, Length, Chest circum, Abd circum? 6. Weigh the newborn? 7. What is worn for all physical assessments until discharge?

1. Bulb syringe is used for suctioning excess mucus from the mouth (first) and nose of newborn 2. Stethoscope w/pediatric head. Listen to apical 3. Axillary route to monitor/prevent hypothermia. Rectal temps are avoided bc they can injure the delicate rectal mucosa 4. BP cuff thats 2.5 cm wide. Can be done on all 4 extremities. 5. Measure from crown to heel of foot for length. Measure head circumference at greatest diameter (occipital to frontal). Measure chest circumference beginning at the nipple line. Measure Abdominal circumference above the umbilicus 6. Scale w/ protective cover that is zeroed out. 7. Clean gloves

Physical Exam From Head to Toe: - Musculoskeletal: 1. How do we rule out Congenital Hip Dysplasia? 2. How are each of these maneuvers performed? 3. What is important to know about the expected number of creases on the palms?

1. By conducting either Barlow or Ortolani maneuvers 2. Barlow maneuver: adducts infant thighs and applies gentle downward pressure. Dislocation = femoral head slips out - this can be felt - Ortolani maneuver: downward pressure on hip, then inward rotation - if dislocated this will force the femoral head back and will hear a "clunk" 3. Should have 2 long transverse creases on palms. If only 1 crease could mean Downs

Respiratory Assessments: Significant Alterations that need to be reported and intervened: - What are 4 Significant Alteration in respiratory function that need to be reported

1. COARSE breath sounds 2. ABNORMAL RATE or apnea longer than 15 secs (requiring stimulation / oxygen) 3. ABNORMAL COLOR: Pallor, grey, central or circumoral cyanosis 4. SIGNS OF LABORED BREATHING: grunting, flaring, retracting, see-saw resp pattern

Physical Exam From Head to Toe: - Head: 1. What is Caput Succedaneum? 2. What are Cephalohematomas?

1. Caput Succedaneum - Localized swelling of the soft tissues of the scalp caused by pressure on the head during labor. It is an expected finding that can be palpated as a soft edematous mass and can cross over the suture line. Usually resolves in 3-4 days and does not require treatment.. 2. Cephalohematoma - Collection of blood btwn the periosteum and the skull bone that it covers. It does not corss the suture line. It results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in the first 1 to 2 days after birth and resolve in 2-3 weeks

Physical Exam From Head to Toe: - Chest: 1. Chest should be ______ shaped 2. Respirations are primarily ________. Chest and abdomen should _______ 3. ______ should be intact 4. There should be an absence of ______ 5. Nipples should be ____, _____, and _______ 6. Breast nodules can be ____ to ____ mms 7. ___-____ breathing is not normal and should be reported

1. Chest should be barrel-shaped 2. Respirations are primarily diaphragmatic. Chest and abd should rise together 3. Clavicles should be intact 4. Absence of retractions 5. Nipples should be prominent, well-formed, and symmetrical 6. Breast nodules can be 3 to 10 mm 7. See-saw breathing

Physical Exam From Head to Toe: - Skin: 1. Skin color 2. Skin turgor 3. Skin Texture 4. Vernix Caseosa 5. Lanugo

1. Color: Should be pink or acrocyanotic with no jaundice present within first 24 hrs. Secondary to increased bilirubin, jaundice can appear on the 3rd day of life, but then decreases spontaneously. 2. Turgor should be present, showing that the newborn is well hydrated. The skin should spring back immediately when pinched 3. Texture: Should be dry, soft, and smooth, showing good hydration. Cracks in hands and feet can be present. In full-term newborns, desquamation (peeling) occurs a few days after birth 4. Vernix Caseosa (protective, thick, cheesy covering): Amounts vary, with more present in creases and skin folds. 5. Lanugo (fine downy hair): Varies regarding the amount present. It is usually found on the pinnae of ears, forehead, and shoulders

Cardio Assessment: 1. What are 2 common variation in HR? 2. What significant alterations need to be reported?

1. Common: HR may be low (80) when deep sleep or 180's when crying. Functional murmurs common first few days 2. Significant Alteration to be reported: - ALL Murmurs, Abnormal rates / rhythms, Absent or unequal pulses - Mottled or harlequin skin color

Diagnostic and Therapeutic Procedures Following Birth: 1. What is collected at birth and tested? 2. A CBC can be done by a _____ to evaluate for ____, ____, ____, or ______.

1. Cord blood is collected at birth. Lab tests are conducted to determine ABO blood type and Rh status if the mother's blood type is "O" or she is Rh-negative. 2. CBC can be done by a capillary stick in the heel to evaluate for anemia, polycythemia, infection, or clotting problems. - Blood glucose is done to evaluate for hypoglycemia

Physiologic Response of Newborn to Birth: 1. What is the most critical extra-uterine adjustment? 2. Circulatory changes after birth occur with the _________ and the __________. 3. The three ______ (______, _____, _______) functionally ______ during a newborns transition to extra-uterine life with the ________

1. Establishment of respiratory function with the cutting of the umbilical cord is the most critical extra-uterine adjustment as air inflate the lungs with the first breath. 2. Circulatory changes after birth occur with the expulsion of the placenta and the cutting of the umbilical cord as a newborn begins breathing independently. 3. The tree shunts (Ductus arteriosus, Ductus Venosus, and Foramen Ovale) functionally close during a newborn's transition to extra-uterine life with the flow of oxygenated blood in the lungs and readjustment of atrial blood pressure in the heart

Physical Exam From Head to Toe: - Ears: 1. What do we do to examine the placement of the ears? Why is this important/what does it help us detect? 2. Cartilage should be _______ and ____. Lack of cartilage indicates __________. 3. The newborn should respond to ______ 4. Inspect each ear for _____

1. Examine placement of ears by drawing an imaginary line through the inner to the outer canthus of the newborn's eye. The eye should be even with the upper tip of the pinna of the newborn's ear. Ears that are low-set can indicate chromosome abnormality, such as Down Syndrome or a kidney disorder 2. Cartilage should be firm and well formed. Lack of cartilage indicates prematurity. 3. Newborns should respond to voices and sounds 4. Inspect ears for skin tags

Initial Assessment: 1. External Assessment: What are the 7 things we are looking for? - What can Meconium Staining indicate? 2. What do we look for during a Chest assessment? 3. What do we look for during an Abdominal assessment

1. External Assessment: - Skin color, Peeling, Birthmarks, Foot creases, Breast tissue, Nasal patency, and Meconium staining - Can indicate fetal hypoxia 2. Chest: - PMI location, Ease of breathing, Auscultation of HR and quality of tones, Respirations for crackles, wheezes, and equality of bilateral breath sounds 3. Abdomen: - Rounded abdomen and umbilical cord with 1 vein 2 arteries.

Physical Exam From Head to Toe: - Anogenital: 1. Genitalia of a female should include _____ covering the ____ and ______, and are usually ______ 2. Vaginal blood-tinged discharge can occur in female newborns, which is caused by _______. This is a ______ finding. 3. A ______ tag should be present 4. Urine should be passed within ____ hrs after birth. 5. _________ will produce a rust color in the urine the first _____ of life

1. Genitalia of a female should include the labia majora covering the labia minora and clitoris, and are usually edematous 2. Vaginal blood-tinged discharge can occur in female newborns, which is caused by maternal pregnancy hormones. This is an expected finding 3. A hymenal tag should be present. 4. Urine should be passed within 24 hrs after birth 5. Uric Acid Crystals will produce a rust color in the urine the first couple of days of life.

Physical Exam From Head to Toe - Senses: Hearing: 1. Hearing is similar to an adult once the ___________ from the ears 2. Newborns exhibit _________ to familiar voices and rhythms of ________ 3. Newborns should ________

1. Hearing is similar to an adult once the amniotic fluid drains from the ears 2. Newborns exhibit selective listening to familiar voices and rhythms of intrauterine life 3. Newborns should turn towards the general direction of sound

Diagnostic and Therapeutic Procedures Following Birth: - Expected Lab Values for: 1. Hgb 2. Platelets 3. Hct 4. Glucose 5. RBC count 6. Bilirubin: 24 hr, 48 hr, and 3-5 days after ranges 7. Leukocytes (WBCs)

1. Hgb: 14-24 g/dL 2. Platelets: 150,000 to 300,000 /mm3 3. Hct: 44% to 64% 4. Glucose: 40-60 mg/dL 5. RBC Count: 4.8 x 10^6 to 7.1 x 10^6 6. Bilirubin: 24 hrs = 2 to 6 mg/dL 48 hrs = 6 to 7 mg/dL 3-5 days = 4 to 6 mg/dL 7. WBC = 9,000 to 30,000/mm3

Classification after physical assessment, classification of newborn by gestational age and birth weight is determined: 1. Intrauterine Growth Restriction (IUGR) 2. Term 3. Preterm or Premature 4. Postterm (postdate) 5. Postmature

1. IUGR: Growth rate does not meet expected norms 2. Term: Birth between the beginning of week 37 and prior to the end of 42 weeks of gestation 3. Preterm/Premature: Born prior to the completion of 37 weeks of gestation 4. Postterm/Postdate: Born after the completion of 42 weeks gestation 5. Postmature: Born after the completion of 42 weeks of gestation with evidence of placental insufficiency

Assessing Overall Activity Level: 1. Infant should be 5 things 2. What are 3 abnormalities we should be on the look out for?

1. Infants should be: - Active - Good tone and movement - Alert while awake (Flexed at rest) - Have a strong lusty cry - Be consolable 2. Abnormalities: - Limp "floppy" tone - Excessively irritable, inconsolable - Rigid, "Jittery"

Physical Exam From Head to Toe: Ears: - What 4 things should you report?

1. Low set-ears 2. Skin tags, dimples 3. No response to sound 4. If infant fails hearing screening

Physical Exam From Head to Toe: - Posture: 1. What are we looking for when assessing Posture?

1. Lying in a curled-up position with arms and legs in moderate flexion. - Resistant to extension of extremities

Physical Exam From Head to Toe: - Skin: Normal Deviations: 1. What is Milia? 2. What are Mongolian Spots? 3. What are Telangiectatic Nevi (Stork bites)?

1. Milia: Small raised white spots on the nose, chin and forehead. Can be present and disappear spontaneously w/o treatment (parents should NOT squeeze the spots) 2. Mongolian Spots: Blueish purple spots of pigmentation. Commonly noted on shoulders, back and buttocks. Frequently present on newborns who have dark skin. Be sure parents are aware of mongolian spots and document location and presence. 3. Telangiectatic Nevi (Stork bites): Flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of the forehead. Usually fade by 2nd yr of life.

Complications: Hypothermia: 1. What do we need to monitor? 2. If temp is unstable, what do we do? 3. What is the ideal method for promoting warmth and maintaining neonate's body temperature for a stable newborn? 4. If the newborn does not remain __________ during the first 1 to 2 hrs after birth, the nurse places the thoroughly dried infant ___________ until _______ 5. How often do we assess temp? 6. Where should all exams and assessments take place?

1. Monitor Axillary temp. Healthy newborn skin temp is approx 36.5 to 37 C (97.7 to 98.6 F) 2. If temp unstable, place newborn in a radiant warmer and maintain skin temp at approx 36.5 C 3. Ideal method is skin-to-skin contact with mom. 4. If the newborn does not remain skin-to-skin during the first 1 to 2 hrs after birth, the nurse places the thoroughly dried infant under the radiant warmer or in a warm incubator until body temp stabilizes 5. Check Axillary temp every hour until stable 6. All exams and assessments should be performed under a radiant warmer or during skin-to-skin contact with the mother

Physical Exam From Head to Toe: - Reflexes: Expected findings and expected age it diminishes 1. Moro Reflex 2. Tonic Neck Reflex (Fencer Position) 3. Babinski Reflex 4. Stepping Reflex

1. Moro: Elicit by allowing the head and trunk of the newborn in a semisitting position to fall backward to an angle of at least 30 degrees. Newborn will symmetrically extend and then abduct the arms at the elbows and fingers spread to form a "C" - Birth to 6 months 2. Tonic Neck: With newborn in supine, neutral position, examiner turns newborn's head quickly to one side. The newborn's arm and leg on that side extend and opposing arm and leg flex. - Birth to 3-4 months 3. Babinski: Elicit by stroking outer edge of sole of foot, moving up towards toes. Toes will fan upward and out. - Birth to 1 yr 4. Stepping: Elicit by holding newborn upright with feet touching a flat surface. The newborn responds with stepping movements. - Birth to 4 weeks

Physical Exam From Head to Toe: - Neck: 1. Neck should be _____, _____, surrounded by ______, and exhibit no _______ 2. Neck should move _______ 3. Absence of head control can indicate ______ or ______ 4. What can Webbing be a sign? 5. What can Large fat pad between occiput and shoulders be a sign of?

1. Neck should be short, thick, surrounded by skin folds, and exhibit no webbing. 2. Neck should move freely from side to side and up and down. 3. Absence of head control can indicate prematurity or Down Syndrome 4. Webbing (Turners syndrome) 5. Fat pad (Downs)

Initial Assessment: 1. What do we look for during a Neurologic assessment? 2. What other things are we assessing for?

1. Neurologic: - Muscle tone and reflex reaction (Moro reflex) - Palpation for the presence and size of fontanels and sutures - Assessment of fontanels for fullness or bulge 2. Other Observations: - Inspection for gross structural malformations

Physical Exam From Head to Toe: - Skin: Normal Deviations: 1. Nevus Flammeus (Port Wine Stains) 2. Erythema Toxicum (Erythema Neonatorum)

1. Nevus Flammeus: Capillary angioma below the surface of the skin that is purple or red, varies in size and shape, is commonly seen on the face, and does not blanch or disappear. 2. Erythema Toxicum: Pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks. This is frequently referred to as newborn rash. No treatment is required

Physical Exam From Head to Toe - Senses: Vision 1. Newborn should be able to focus on objects ___ to ____ inches away from face. This is approx the distance from the mother's face when the infant is ________. 2. The eyes are sensitive to ______, so newborns prefer ____ 3. Pupils are ______ to ____ and _______ is easily stimulated. 4. The newborn can track _______ and prefers ____ and ____. 5. Term newborns can see objects as far away as _____ feet. 6. Within _____ to ___ months, they can _______

1. Newborns should be able to focus on objects 8 to 12 inches away from face. This is approx the distance from the mothers face when the infant is breast feeding 2. The eyes are sensitive to light, so newborns prefer dim lighting 3. Pupils are reactive to light, and the blink reflex is easily stimulated. 4. Newborns can track high-contrast objects and prefer bright colors and patterns 5. Term newborns can see objects as far away as 2.5 feet. 6. Within 2 to 3 months, they can discriminate colors

Physical Exam From Head to Toe - Senses: Touch, Taste, Smell, Habitation: 1. Newborns should respond to _____ of ___ and ___. The ____ is the area most sensitive to touch in a newborn 2. Newborns can taste and prefer ____ to ____, ____, or _____ 3. Newborns have a ______ developed sense of smell and prefer ____ smells and can recognize the _______ smell 4. What is Habitation? What does this allow for?

1. Newborns should respond to tactile messages of pain and touch. The mouth is the most sensitive to touch in a newborn 2. Newborns can taste and prefer sweet to salty, sour, or bitter 3. Newborns have a highly developed sense of smell and prefer sweet smells, and can recognize the mother's smell 4. Habitation is a protective mechanism whereby the newborn becomes accustomed to environmental stimuli. Response to a constant or repetitive stimulus is decreased. This allows the newborn to select stimuli that promotes continued learning, avoiding overload

Respiratory Assessments: 1. What is considered normal? 2. What are common variations?

1. Normal: RR 30-60. Normally irregular, shallow, unlabored breaths, equal and clear breath sounds bilaterally. 2. Common Variations: Need for suctioning/ slightly coarse breath sounds. Brief cyanotic episodes assoc. with secretions /brief need for oxygen

Physical Exam From Head to Toe: - Nose: 1. The nose should be _______, _______, and ____ with lack of a _______. 2. Some mucus should be present, but with no___________ 3. Newborns are _________ breathers and do not develop the response of ______ with a _____ untill 3 weeks after birth. Therefore, a nasal ______ can result in _____, ____, or _______ 4. Newborns ____ to clear nasal passages

1. Nose should be midline, flat, and broad with lack of a bridge 2. Some mucus should be present, but with not drainage. 3. Newborns are obligate nose breathers and do not develop the response of opening the mouth with a nasal obstruction until 3 weeks after birth. Therefore, a nasal blockage can result in flaring of the nares, cyanosis, or asphyxia. 4. Newborns sneeze to clear nasal passages

Gestational Age Assessment: 1. When is this performed? 2. What 2 things are related to gestational age and birth weight? 3. What scale do we use? What does this measure? 4. Explain how this scale is used

1. Performed on newborns within the first 48 hrs of birth. 2. Neonatal morbidity and mortality are related to gestational age and birth weight 3. New Ballard Scale: Assesses Neuromuscular and Physical Maturity 4. Each individual assessment parameter displays at least 6 ranges of development along a continuum. Each range of development within an assessment is assigned a number value from -1 to 5. The totals are added to give a maturity rating in weeks gestation. (eg a score of 35 indicates 38 weeks of gestation)

Physical Exam: Musculoskeletal: - What are 6 Common Abnormalities that we should report

1. Polydactyly 2. Syndactyly 3. Single palmar crease (trisomy 21) 4. Club foot/feet (cannot be palpated out) 5. Brachial Palsy - trauma to brachial plexus: complete or partial paralysis of portions of arm. Most common with difficult birth 6. Erb-Duchene Paralysis (Erb Palasy): Damage to upper arm. Arm lies limp and moro is not possible

Gestational Age Assessment: New Ballard Scale: Calculating Neuromuscular Maturity: - What are the 6 things we assess to determine Neuromuscular Maturity?

1. Posture: ranging from fully extended to fully flexed (0 to 4) 2. Square window: formation with the neonate's wrist (-1 to 4) 3. Arm recoil: where the neonate''s arm is passively extended and spontaneously returns to flexion (0 to 4) 4. Popliteal angle: which is the degree of the angle to which the newborn's knee can extend (-1 to 5) 5. Scarf Sign: which is crossing the neonate's arm over the chest (-1 to 4) 6. Heel to ear: which is how far the neonate's heels reach to her ears (-1 to 4)

Vital Signs for Newborns: 1. What is the order that we check vital signs? 2. RR: Range, Periods of apnea, Crackles and wheezes, Grunting and nasal flaring

1. RR, HR, BP, Temp. - The nurse assesses RR first before the newborn becomes active or agitated by the use of the stethoscope, thermometer, or BP cuff 2. RR 30-60 breath/min with short periods of apnea (less than 15 seconds) occurring most frequently during REM sleep cycle. - Apnea longer than 15 sec should be evaluated - Crackles and wheezes are manifestations of fluid or infection in the lungs - Grunting and Nasal flaring indicate respiratory distress

Complications: Inadequate Oxygen Supply: 1. What is Inadequate Oxygen Supply related to? 2. What are 2 nursing considerations for a newborn with Inadequate Oxygen Supply?

1. Related to obstructed airway, poor functioning cardiopulmonary system, or hypothermia 2. - Monitor respirations and skin color for cyanosis - Stabilize body temp or clear airway as indicated, administer oxygen, and if needed, prepare for resuscitation.

Vital Signs for Newborns: 1. BP range for SBP and DBP 2. What is the normal Temperature range? 3. Related to temperature, what are newborns at risk for?

1. SBP should be 60-80 and DBP should be 40-50 2. Temperature Range: 36.5 to 37.5 C (97.7 to 99.5 F) axillary. 3. Newborns are at risk for hypothermia and hyperthermia until thermoregulation stabilizes. - If the newborn becomes chilled (cold stress), oxygen demands can increase and acidosis can occur

Physical Exam From Head to Toe: Chest: - What are 5 things to report that are considered significant abnormalities?

1. Scaphoid or concave shaped chest 2. Opening in abd wall 3. Abd distension, ascites, localized bulging 4. Absent bowel sounds (after feeding well-established) 5. No retractions

Gestational Age Assessment: New Ballard Scale: Calculating Physical Maturity: - What are the 6 things we assess to determine Physical Maturity?

1. Skin Texture: ranging from sticky and transparent, to leathery, cracked, and wrinkled (-1 to 5) 2. Lanugo: presence and amount, ranging from none, sparse, abundant, thinning, bald, or mostly bald (-1 to 4) 3. Plantar Surface Creases: ranging from less than 40 mm to creases over the entire sole (-1 to 4) 4. Breast Tissue Amount: ranging from imperceptible, to full areola with a 5 to 10 mm bud (-1 to 4) 5. Eyes and Ears for amount of eye opening and ear cartilage present (-1 to 4) 6. Genitalia Development: ranging from flat smooth scrotum to pendulous testes with deep rugae for males (-1 to 4) and prominent clitoris with flat labia to labia majora covering the labia minora and clitoris for females (-1 to 4)

Physical Exam From Head to Toe: - Spine 1. Spine should be _____, ____, ____ and easily _____ 2. What are 4 Abnormalities of the back that need to be reported?

1. Spine should be straight, flat, midline, and easily flexed 2. - Indentations (dimples) along the spinal cord - Areas covered only by meninges - Protrusion of neural tube - Grossly crooked spinal cord or masses

Physical Exam From Head to Toe: - Reflexes: Expected findings and expected age it diminishes 1. Sucking and Rooting Reflex 2. Palmar Grasp 3. Plantar Grasp

1. Sucking and Rooting Reflex: Elicit by stroking the cheek or edge of mouth. Newborn turns the head toward the side that is touched and starts to suck. - Birth to 3-4 months, but can persist up to 1 year 2. Palmar Grasps: Elicit by placing examiner's finger in palm of the newborns hand. Newborn's fingers curl around examiner's finger. - From Birth to 3-4 months 3. Plantar Grasp: Elicit by placing examiner's finger at base of toes. Newborn responds by curling toes downward. - From Birth to 8 Months

Physical Exam From Head to Toe: Eyes - What are 3 normal variations associated with Eyes that we should note?

1. Transitional strabismus 2. Slight edema 3. Slight hemorrhage

Physical Exam From Head to Toe: - Abdomen: 1. Umbilical cord should be _____ and exhibit no _____. 2. Abdomen should be ____, ____ shaped and non-_________ 3. Bowel sounds should be present ____ to ____hrs following birth

1. Umbilical cord should be odorless and exhibit no intestinal structures 2. Abdomen should be round, dome-shaped, and non-distended. 3. Bowel sounds should be present 1 to 2 hours following birth

Initial Assessment: - What are the expected reference ranges for: 1. Weight 2. Length 3. Head Circumference 4. Chest Circumference

1. Weight: 2,500 to 4,000 grams (5.5-8.8 lbs) 2. Length: 45 to 55 cm (18-22 in) 3. Head Circumference: 32 to 36.8 cm (12.6-14.5 in) 4. Chest Circumference: 30 to 33 cm (12-13 in)

Physical Exam From Head to Toe: - Head: Caput Succedaneum vs Cephalohematoma: - What 7 things should you report?

Report: 1. Absence of cranial plates 2. Non-palpable, depressed, or bulging fontanelles 3. Abnormal head circum 4. Wide or non-palpable sutures 5. Abrasions 6. Caput succedaneum 7. Cephalhematoma