Neonate Assessment by Area or System

Pulse

Technique: Assess apical pulse rate by auscultating for 1 full minute. Assess rate and rhythm. Use of a stethoscope designed for neonates is recommended. Expected: 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: achycardia (>160 bpm) indicates possible sepsis, pain, respiratory distress, or congenital heart abnormality. Bradycardia (<100 bpm) indicates possible sepsis, increased intracranial pressure, or hypoxemia.

Respirations

Technique: Assess respiratory rate by auscultating and observing the rise and fall of the chest and abdomen (without clothing) for 1 full minute. Expected: 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.

Eyes

Technique: Assess the position of the eyes. Open the eyelids and assess the color of sclera and pupil size. Assess for blink reflex, red light reflex, and pupil reaction to light. Expected: 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.

Blood Pressure

Technique: Blood pressure is not a routine part of neonatal assessment. Requires the use of specially designed equipment for neonates. The blood pressure is obtained from either the arm or leg of the neonate. Expected: 50-75/30-45 mmHg

Weight

Technique: Clean scale before use. Place clean paper on the scale. Set the scale at zero. Place the naked neonate on the scale. Record the neonate's weight. Do not leave the neonate unattended while weighing. Expected: 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%.

Ears

Technique: Inspect the ears for position, shape, lesions, skin tags, dimples, or drainage. Hearing test is done before discharge. Expected: 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.

Integumentary/Skin

Technique: Inspect the skin for color, intactness, bruising, birth marks, dryness, rashes, warmth, texture, and turgor. Inspect nails. Expected: 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; see Table 15-4) 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 (see Table 15-4). 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 (see Chapter 17). 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.

Chest Circumference

Technique: Measure by placing tape around the chest over the nipple line Expected: 30.5-33 cm (12-13 in.) or 2-3 cm less than head circumference

Head Circumference

Technique: Measure by placing tape around the head just above the ears and eyebrows. Measurement is usually recorded in centimeters. Expected: 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.

Length

Technique: Measure the length of body by securing tape on a flat surface. Place the top of the neonate's head at the top of the tape. Extend the body and one leg. Measurement is taken from the top of the head to the bottom of the heel. Expected: 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.

Head

Technique: Note the shape of the head. Inspect and palpate fontanels and suture lines. Inspect and palpate the head for caput succedaneum or cephalohematoma Expected: Molding present (see Table 15-4). 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

Temperature

Technique: Place a clean temperature probe in the axillary area. Axillary temperatures are preferred in the hospital setting but rectal temperatures may also be done. Rectal temperatures are considered the most accurate. Expected: 97.7 - 99 Abnormal: hypothermia or hyperthermia is related to infection, environmental extremes, or neurological disorders.

Pulse Oxygen Saturation Levels

Technique: Pulse oximetry is not routinely done with vital signs but may be done when there is respiratory distress or other concerns. Also used in screening for CCHD. Requires a neonatal-specific sensor. Expected: Oxygen saturation levels are low at birth and rise over the first 10 minutes. >95%

Nose

Technique: observe shape and inspect openings Expected: 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.

Posture

Technique: unwrap newborn and observe posture when newborn is quiet Expected: 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).

Neck

Techniques: Lift chin to assess neck area Expected: Short with skin folds; positive tonic neck reflex Abnormal: webbing or large thick skin folds; absent tonic neck reflex indicative of nerve injury