Assessment of Newborn

1. Assessment of NB
Physical exam
General appearance. This looks at physical activity, muscle tone, posture, and
level of consciousness.
Skin. This looks at skin color, texture, nails, and any rashes.
Head and neck. This looks at the shape of head, the soft spots (fontanelles) on the baby’s
skull, and the bones across the upper chest (clavicles).
Face. This looks at the eyes, ears, nose, and cheeks.
Mouth. This looks at the roof of the
mouth (palate), tongue, and throat.
Lungs. This looks at the sounds the baby makes when he or she breathes. This also
looks at the breathing pattern.
Heart sounds and pulses in the groin (femoral)
Abdomen. This looks for any masses or hernias.
Genitals and anus. This checks that the baby has open passages for urine and stool.

2. Physical maturity
Skin textures. Is the skin sticky, smooth, or peeling?
Soft, downy hair on the baby’s body (lanugo). This hair is not found on
immature babies. It shows up on a mature infant, but goes away for a
postmature infant.
Plantar creases. These are creases on the soles of the feet. They can be
absent or range up to covering the entire foot.
Breast. The provider looks at the thickness and size of breast tissue and the
darker ring around each nipple (areola).
Eyes and ears. The provider checks to see if the eyes are fused or open. He
or she also checks the amount of cartilage and stiffness of the ears.
Genitals, male. The provider checks for the testes and how the scrotum
looks. It may be smooth or wrinkled.
Genitals, female. The provider checks the size of the clitoris and the labia
and how they look.

3. Maturity of nerves and muscles
• The healthcare provider does 6 checks of the baby's nerves and muscles.
• A score is given to each area looked at. Typically, the more mature the baby is,
the higher the score. These are the areas checked:
• Posture. This looks at how the baby holds his or her arms and legs.
• “Square window.” This looks at how far the baby's hands can be flexed toward
the wrist.
• Arm recoil. This looks at how much the baby's arms "spring back" to a flexed
position.
• Popliteal angle. This looks at how far the baby's knees extend.
• “Scarf sign.” This looks at how far the baby’s elbows can be moved across the
baby's chest.
• Heel to ear. This looks at how near the baby's feet can be moved to the ears.

7. - gestational age is examined within 4 hours
after birth to identify any potential age-related
problems that may occur within the next few
hours.
- neuromuscular and physical maturity are
examined.

14. 1. You’re assessing the one minute APGAR score of a
newborn baby. On assessment, you note the following about
your newborn patient: heart rate 130, pink body and hands
with cyanotic feet, weak cry, flexion of the arms and legs,
active movement and crying when stimulated. What is your
patient’s APGAR score?
C: APGAR 8.....A: 1, P: 2, G, 2, A: 2, R: 1

15. You’re assessing the one minute APGAR score of a newborn baby. On
assessment, you note the following about your newborn patient:
heart rate 101, cyanotic body and extremities, no response to
stimulation, no flexion of extremities, and strong cry. What is your
patient’s APGAR score?
A: APGAR 4.....A: 0, P: 2, G, 0, A: 0, R: 2

16. On assessment, you note the following about your newborn patient:
weak cry, some flexion of the arm and legs, active movement and cries
to stimulation, heart rate 145, and pallor all over the body and
extremities. What is your patient’s APGAR score?
The answer is D: APGAR 6.....A:
0, P: 2, G, 2, A: 1, R: 1

17. You’re assessing the five minute APGAR score of a newborn baby. On
assessment, you note the following about your newborn patient: pink
body and hands with cyanotic feet, heart rate 109, grimace to
stimulation, flaccid, and irregular cry. What is your patient’s APGAR
score?*
The answer is D. APGAR 1:...A: 0, P: 1, G, 0, A: 0, R:
0

18. A newborn's five minute APGAR score is 5. Which of the following
nursing interventions will you provide to this newborn?
Scoring Interventions are as follows: 7-10: no interventions, baby doing good just needs routine post-
delivery care, 4-6: some resuscitation assistance required like oxygen, suction…. stimulate the baby, rub
baby's back, 0-3: needs full resuscitation

19. Regarding the scenario in the question above, when would you
reassess the APGAR?*
. The APGAR score is performed at 1 minute and 5 minutes after birth and reassessed at 10
minutes (5 minutes later) after birth, IF the score is 6 or less. Therefore, in this scenario since the
APGAR score was less than 6 at the routine 5 minute APGAR assessment, the nurse would
reassess the APGAR score 5 minutes later (hence 10 minutes post birth).

20. You’re assessing the five minute APGAR score of a newborn baby. On
assessment, you note the following about your newborn patient: pink
body and hands with cyanotic feet, heart rate 109, grimace to
stimulation, flaccid, and irregular cry. What is your patient’s APGAR
score?*
The answer is B. APGAR 5:...A: 1, P: 2, G, 1, A: 0, R:
1

21. On assessment, you note the following about your newborn patient:
heart rate 97, no response to stimulation, flaccid, absent respirations,
cyanotic throughout. What is your patient’s APGAR score?
The answer is D. APGAR 1:...A: 0, P: 1, G, 0, A: 0, R:
0