Neonatal Assessment Guide

Felician College Department of Nursing and Health Management Nursing 370 Neonatal Assessment Guide / Independent Study Nursing students will perform the following newborn assessment with the clinical instructor’s assistance during the clinical nursing experience. The purpose of this assessment is to increase the student’s knowledge about newborn physical assessment and to increase the student’s observational skills. • The clinical instructor will assign students the week before this assignment is due. • Students are required to complete the column entitled “Norms & Possible Alterations” prior to meeting with the clinical instructor for the hands-on clinical newborn assessment. • Students will describe fully what they see, hear, and feel during the clinical newborn assessment in the column entitled “Description of Findings” (this will be handed in the week following the experience to the clinical instructor). • References other than course textbooks must be listed. • Grading will be O =outstanding, S = satisfactory, or U = unsatisfactory Neonate’s Initials

Student Name

Assessment Areas

Norms/Possible Alterations

General Appearance Briefly describe (ex, dark hair, pink, flexed)

Head disproportionately large for the body, neck looks short, chin rests on chest, prominent abdomen, sloping shoulders, narrow hips, rounded chest

Grade Description of Findings

Weight & Measurement 1. Weight – include range 2500-4000 g (5lb, 8oz., -8 & average lbs.13 oz.) 2. Height – include range & average

48 – 52 cm (18 -22 in.)

3. Temperature Axillary-

36.4 – 37.2C (97.5 – 99F)

Rectal (optional)

36.6-37.2C (97.8-99F) 36.8 C (98.8F) desired 32-37cm (12.5-14.5 in.) 2cm Greater than chest circumference

4. Head Circumferance

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5. Chest Circumference Posture: briefly describe Skin 1. Color

2. Texture

3. Turgor

4. Pigmentation

32.5 cm, 1-2 cm less than head Wider than it is long Body usually flexed, hands may be tightly clenched, and neck appears short because chin rests on chest. Consistent with race. European- pink-tinged, African or Native American pale pink with yellow tinge, Asian –pink to rosy red, yellow tinge. Smooth, soft, flexible, may have dray, peeling hands and feet. Elastic, returns to normal shape after pinching Clear, milia across bridge of nose, forehead, or chin will disappear within a few weeks

5. Jaundice

6. Normal Variations Ex. Rashes, ET rash, Mongolian spots, birthmarks, bruises, petechiae.

Café-au-lait spots (one or two) Mongolian blue spots common over dorsal area and buttocks in dark-skinned infants Erythema toxicum Telangiectatic nevi, rashes Petechiae of head or neck

Head Assessment 1. General appearance

Round, symmetric, and moves easily from left to right and up and down, soft and pliable 2. Size (related to body) Greater than chest circumference, head one fourth of body size 3. Common Variations Molding Define and explain the Caput succedaneum (long differences between labor and birth disappears in 1 Caput Succedaneum & week, cephalhematoma(trauma Cephalhematoma. during birth, may persist up to 3 months)

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4. Fontanels A. Anterior Fontanel B. Posterior Fontanel

Palpation of juncture of cranial bones 3-4cm long by 2-3 cm wide diamond shaped 1-2 cm at birth, triangle shaped

C. Pulsation?

Slight pulsation

D. Bulging

Moderate bulging noted with crying, stooling; pulsations with heartbeat -

E. Sunken

Hair 1. Texture 2. Distribution Face 1. Symmetry 2. Spacing of features 3. Movement

Smooth with fine texture variations, depends on ethnic background Scalp hair high over eyebrows (Spanish-Mexican hairline begins midforehead to neck) Symmetric movement of all facial features, normal hairline, eyebrows & eyelashes present Eyes-ears at same level, nostrils equal size, cheeks full, and sucking pads present Makes facial grimaces Symmetric when resting and crying

Eyes 1. General placement and Bright and clear; even appearance placement, slight nystagmus (involuntary cyclic eye movement) 2. Color Blue-gray or slate-blue-gray Brown color at birth in darkskinned infants 3. Any tears? React to light by accommodation, light reflex demonstrated at birth or by 3 4. Pupils react to light? weeks of age

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5. Subconjunctival hemorrhage? Nose 1. General appearance

Chemical conjunctivitis, Subconjunctival hemorrhage

May appear flattened as a result of birth process

2. Any sneezing?

Sneezing common to clear nasal passages

3. Occlude one nostril at a time to check for Choanal Atresia

Patent nares bilaterally ( nose breathers)

Mouth 1. Symmetry? 2. Check for cleft palate 3. Tongue Ears 1. Position on head relative to eyes

Symmetry of movement and strength Hard palate dome shaped, uvula midline with symmetric movement of soft palate, palate intact Tongue free moving in all directions, midline Top of ear (pinna) should be parallel to the outer and inner canthus of the eyes

2. Symmetry? 3. Preauricular skin tag? 4. Cartilage (does the ear spring back when folded)

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Neck 1. Appearance 2. Mobility Clavicles 1. Appearance &size

Short, straight, creased with skin folds, posterior neck lacks loose extra folds of skin Moro reflex elicitable

Straight and intact

2. Expansion and/or retractions

Bilateral expansion

3. Breast tissue (measure and describe)

Flat with symmetric nipples Breast tissue diameter 5 cm or more at term; average distance between nipples 8 cm.

4. Auscultate breath sounds

5. Describe general breathing movements

Breath sounds are louder in infants, chest and axilla clear on crying, air entry clear, rales may indicate normal newborn atelectasis No inercostal, subcostal, or supraclavicular retractions

6. Respiratory rate (one minute)

30- 60 bpm and predominately diaphragmatic

7. What can make the RR Brief periods of apnea with no vary? color or heart rate changes in healthy newborns

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Heart 1. Palpate for PMI & describe

Usually lateral to midclavicular line at third or fourth intercostal space

2. Auscultate heart sounds for one minute & describe

Regular rate and rhythm, no functional murmurs, 120160bpm

3. Any murmur?

No functional murmurs

4. Any thrills? Define a thrill.

No thrills Vibration created by turbulence of fluid passing through an incompetent valve Normal 120-160 bpm, if asleep as low as 80 bpm, if crying up to 180 bpm

5. What makes the HR vary Abdomen 1. Appearance 2. Any Diastasis Recti?

Cylindric with some protrusion, appears large in relation to pelvis Common in infants of African Americans

3. Palpate & describe

Some laxness of abdominal muscles

4. Umbiculus

No protrusions of umbilicus ( but, common in African descent) Two arteries and one vein present

5. Number of vessels 6. Auscultate bowel sounds

Soft bowel sounds heard shortly after birth every 10-30 seconds

7. Palpate inguinal area

No bulges along inguinal area

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8. Describe voiding Genitals Male 1. Penis

Emptied about 3 hours after birth or time of birth, inoffensive, mild odor Slender in appearance about 2.5 cm long 1 cm wide at birth

2. Placement of urinary meatus

Normal urinary orifice, urethral meatus at tip of penis

3. Scrotum

Skin loose and hanging or tight and small extensive rugae and normal size, normal color Descended by birth, not consistently found in scrotum 1.5-2 cm at birth

4. Testes Female 1. General appearance 2. Vaginal tag

Normal skin color are pigmented in dark skinned infants Disappears in a few weeks

3. Discharge

Smegma under labia

Buttocks and Anus 1. Symmetry

Symmetric

2. Pilonidal dimple

-

3. Pattern of stools

Meconium within 24-48 hours of birth

Extremities & Trunk 1. General appearance 2. Symmetry

Short and generally flexed, extremities move symmetrically through range of motion but lack full extention Symmetric

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3. Complete a ROM & desribe

All joints move spontaneously; good muscle tone, of flexor type, birth to 2 months

4. Arms (equal)?

Equal in length

5. Assess & explain: Polydactyly

Presence of extra digits on either hands or feet. Should not be present

Syndactyly

Fusion (webbing) of fingers or toes, should not be present

Simian crease

Single palmar crease is frequently present in children with Down Syndrome C- shaped spine Flat and straight when prone Slight lumbar lordosis Easily flexed and intact when palpated No sign of instability Hips abduct to more than 60 degrees Legs equal in length Legs shorter than arms at birth

6. Spine

7. Hips

8. Legs 9. Feet Reflexes 1. Moro 2. Rooting 3. Sucking 4. Palmar grasp

Foot is in straight line Positional clubfoot based on position in utero Response to sudden movement or lout noise should be one of symmetric extension and abduction of arms with fingers extended thane return to normal relaxed flexion Turns in direction of stimulus to check or mouth; opens mouth and begins to suck rhythmically when finger or nipple is inserted into mouth; difficult to elicit after feeding; disappears by 4-7 months

Sucking is adequate for nutritional intake and meeting oral stimulation needs – for 12 months Fingers grasp adult finger when palm is stimulated and held momentarilylessens at 3- 4 months

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5. Plantar grasp

Toes curl downward when sole of foot is stimulated lessens by 8 months

6. Stepping

When held upright and one foot touching a flat surface, will step alternately disappears at 4-8 weeks of age

7. Babinski 8. Tonic neck 9. Trunk incurvation

Activity 1. Neonate cries when?

2. Cry (pitch)

Sensory: What evidence is there that the baby can or cannot: 1. See

Fanning and extension of all toes when one side of sole is stroked from heel upward across ball of foot, disappears at about 12 months Fencer postion – when head is turned to one side, extremities on same side extend and on opposite side flex, this may not be eveident during early neonal period disappears at 3-4 months In prone postion, stroking of spine causes pelvis to turn to stimuated side

Cries vary in length from 3-7 minutes after consoling measures are used Moderate tone and pitch, strong and lusty

Tracks moving object to midline, fixed focus on objects at a distance about 10-20 in., may be difficult to evaluate in newborn, prefers faces, geometric designs and black and white to colors

2. Hear

Attends to sounds, sudden or loud noise elicits more reflex

3. Feel

Accept physical contact, responds to being handled

4. Taste (textbook only)

Can discriminate between sweet and bitter flavors

5. Smell (textbook only)

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