newborn assessment

1. Mary Charlotte B. Pableo
Newborn
Assessment

2. 1. IDENTIFICATION - Check and identify the sex of the infant and
verify the records with the correct name, sex and registration
number.
2. GESTATIONAL AGE
●Check the data of the infant if:
●FULL TERM: 37 – 42 weeks or 259 days to 294 days
●PRE-TERM: After 28 weeks and before 37 weeks
●POST-TERM: After 48 weeks

3. Apgar
Score

4. Apgar Score
APGAR score: It is method use to
assess the newborn's immediate
adjustment to extra uterine life. The
score based on five signs
1. Appearance (colour)
2. Pulse ( Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate

5. Apgar Score
Assessment Procedure
1. Auscultate Apical Pulse
2. Inspect chest and Abdomen for respiratory effort
3. Stroke back soles of feet
4. Inspect muscle tone by extending legs and arms.
Observe degree of flexion and resistance in
extremities.
5. Inspect body and extremities for skin color.

6. Apgar Score
 Each item is given a score o, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
 Evaluation of all five categories are
made on 1- 5 min after birth.
 A score of less than 8 may indicate
poor transition from intrauterine to
extrauterine life.

7. Vital
Signs

8. Check the vital signs in the following order:
A.) RESPIRATION. normal value of respiration is
40-60 breaths/min.
B.) HEART RATE: normal value of heart rate is 120-
140 beats/min,
C.) TEMPERATURE: normal value of temperature is
36.5-37.5 degree Celsius.
D.) BLOOD PRESSURE: only if suspected heart
problem or premature infant
Vital Signs

9. Assessment Procedure:
1. Assess temperature. Use rectal, axillary, skin, or tympanic route
when assessing the temperature of an infant. Temperature is
99.4°F (because of excess heat production). The rectal
temperature is most accurate. To take a rectal temperature in a
newborn, lay the child supine and lift lower legs up into the air,
bending the legs at the hips. Insert lubricated rectal
thermometer no more than 2 cm into rectum. Temperature
registers in 3–5 min on a rectal thermometer.
Vital Signs

10. Assessment Procedure:
2. Axillary and/or tympanic temperature may also be used. For
axillary temperature, place the thermometer under axilla,
holding arm close to chest for approximately 3–5 minutes. For
tympanic temperature, use digital tympanic thermometer as
directed in manufacturer’s instructions.
3. Note apical pulse rate. Count the pulse for a full minute.
Vital Signs

11. Assessment Procedure:
4. Assess respiratory rate and
character. Measure respiratory
rate and character in infants by
observing abdominal movements.
Neonates: Rate is 30–60
breaths/min. Breathing is
unlabored; lung sounds clear.
Newborns are obligatory nose
breathers.
Vital Signs

12. Assessment Procedure:
5. Evaluate infant blood pressure, if necessary. Evaluate newborn
blood pressure: A Doppler stethoscope should be used or an
electronic Dynamap machine may be used to record blood
pressure readings in the newborn.
Vital Signs

13. Clinical Tip!
• If the blood pressure reading is too high for age, the cuff may be
too small; it should cover two-thirds of the infant’s upper arm. If
the blood pressure reading is too low for age, the cuff may be too
large. Chapter 8 explains how to take a blood pressure reading.
• Make sure the newborn or infant is not crying during the
measurement, as this can elevate blood pressure.
Vital Signs

14. VITAL SIGN NORMAL RANGE
Heart rate 120 to 160 beats per minute*
Respiratory rate 40 to 60 breaths per minute
Systolic blood pressure 60 to 90 mm Hg†
Temperature 97.7°F to 99.5°F (36.5°C to
37.5°C)‡

15. Measurement

16. LENGTH: Crown to heel infant supine/ upside down/ —
with the knees slightly pressed down to obtain
maximum leg extension. (47-50 cm)
Determine height by measuring the recumbent length.
Fully extend the body, holding the head in midline and
gently grasping the knees, pushing them downward
until the legs are fully extended and touching the table.
Measurement

17. If using a measuring board, place the
head at the top of the board and the
heels firmly at the bottom. Without a
board, use paper under the infant and
mark the paper at the top of the head
and bottom of the heels. Then measure
the distance between the two points.
Plot height measurement on an age and
gender-appropriate growth chart.
Measurement

18. WEIGHT: Average birth weight 2.5-3.5 kg.
Measure weight on an appropriately sized
beam scale with non detectable weights.
Weigh an infant lying or sitting on a scale that
measures to the nearest 0.5 oz or 10 g Weigh
an infant naked. Plot weight measurement on
age- and gender-appropriate growth chart.
Measurement

19. DETERMINE HEAD/CHEST
CIRCUMFERENCE:
Measure head circumference (HC) or
occipital frontal circumference (OFC)
at every physical examination for
infants and toddlers younger than 2
years and older children when
conditions warrant.
Measurement

20. DETERMINE HEAD/CHEST CIRCUMFERENCE:
If necessary, determine chest circumference by
measuring the chest at the nipple line. Plot the
measurements for both the head and chest on
standardized growth charts specific for gender from
birth to 36 months.
Measurement

21. CULTURE CONSIDERATIONS!
Asian and African American
newborns are smaller than Caucasian
newborns. Asian children are smaller at
all ages.
Measurement

22. Assessment of
Gestational Age

23. Gestational Age
Assess gestational age within 4 hours after birth to identify any potential
age-related problems that may occur within the next few hours. This exam
requires assessing the newborn’s neuromuscular and physical maturity.
Use the Ballard Scale to rate
1. To assess neuromuscular maturity (with the newborn in supine
position): Inspect posture (with the newborn undisturbed). Arms and
Legs are flexed

24. Gestational Age
2. Assess for square window sign. Bend the wrist
toward the ventral forearm until resistance is
met. Measure angle. Angle is 0–30°
3. Assess popliteal angle. Flex the thigh on top of
the abdomen; push behind the ankle and
extend the lower leg up towards the head
until resistance is met. Measure the angle
behind the knee.

25. Gestational Age
4. Assess for Scarf sign. Lift the arm across
the chest toward the opposite shoulder
until resistance is met; note location of the
elbow in relation to midline of the chest.
5. Perform heel-to-ear test. Keeping buttocks
flat on the bed, pull leg toward the ear on
the same side of the body; inspect popliteal
angle and proximity of the heel to the ear.

26. Gestational Age
To assess for physical maturity:
 Inspect the skin. Inspection reveals parchment, few or no vessels on
the abdomen, and crackling, especially in the ankle area.
 Inspect for lanugo. Normally there is thinning and balding on the
back, shoulders, and knees.
 Inspect the plantar surface of the feet for creases. There are creases
on the anterior two thirds or entire sole.
 Inspect and palpate breast bud tissue with the middle finger and
forefinger; measure bud in millimeters. The areola is raised and full.
 Observe ear cartilage in the upper pinna for curving. Fold the pinna
down toward the side of the head and release; note recoil of the ear.
Normally you find a well-curved pinna, well formed cartilage, and
instant recoil.

27. Gestational Age
To assess for physical maturity:
 Inspect the genitals.
Male: Assess scrotum for rugae and palpate position of testes. There are
deep rugae; testes are positioned down in scrotal sac.
Female: Inspect labia majora, labia minora,
and clitoris. The labia majora covers the labia
minora and clitoris.
 Determine score rating: Use the New Ballard Scale. Mark the boxes
that most closely represent each observation. Score totals 35–45.

28. Gestational Age

29. Gestational Age

30. Gestational Age
3. Assess popliteal angle. Flex the thigh on top of
the abdomen; push behind the ankle and
extend the lower leg up towards the head
until resistance is met. Measure the angle
behind the knee.
4. Assess for Scarf sign. Lift the arm across the
chest toward the opposite shoulder until
resistance is met; note location of the elbow in
relation to midline of the chest.

31. Skin, Hair,
And Nails

32.  Assess for skin color, odor, and lesions. Skin
color ranges from pale white with pink,
yellow, brown, or olive tones to dark brown
or black. Acrocyanosis (sluggish perfusion of
peripheral circulation) may be present.
Mottling (general red/white discoloration of
the skin) may be noted when chilled. No
strong odor should be evident, and the skin
should be lesion free.
Skin, Hair, And Nails

33.  Petechiae or bruising may be noted on thepresenting part (head,
buttocks, face chest) in newborns due to rapid pressure and
release with delivery.
Common newborn skin variations include:
• Physiologic jaundice
• Birthmarks
• Milia
• Erythema toxicum
Skin, Hair, And Nails

34. Common newborn skin variations include:
• Telengiectatic nevi (stork bites)
• Café au lait< 1.5 cm
• Benign hemangioma
• Another common variation is harlequin sign (one side of the body
turns red, the other side is pale). There is a distinct color line
separation at midline. The cause is unknown.
Skin, Hair, And Nails

35.  Inspect and palpate hair. Observe for
distribution, characteristics, and presence of
any unusual hair on body. Hair is normally
lustrous, silky, strong, and elastic. Lanugo—
fine, downy hair that covers parts of the
body, such as the shoulders, back, and sacral
area—may been seen in the newborn or
young infant.
Skin, Hair, And Nails

36.  Inspect and palpate nails. Note color,
texture, shape, and condition of nails.
CULTURAL CONSIDERATIONS!
Dark-skinned children have deeper nail pigment. Nails extend
to end of fingers or beyond, and are well-formed.
Skin, Hair, And Nails

37. Eyes
and
Ears

38.  Inspect the external eye. Note the position, slant, and
epicanthal folds of the external eye.
 Observe eyelid placement, swelling, discharge, and lesions.
 Inspect the sclera and conjunctiva for color, discharge,
lesions, redness, and lacerations.
 Perform visual acuity tests. Assess visual acuity by observing
infant’s ability to gaze at an object.
 Perform extraocular muscle tests. Hirschberg test: Shine light
directly at the cornea while the infant looks straight ahead.
Eyes

39.  Inspect external ears. Note placement,
discharge, or lesions of the ears.
 Inspect internal ear. The internal ear
examination requires an otoscope. The nurse
should always hold the otoscope in a manner
that allows for rapid removal if the child
moves. Have the caregiver hold and restrain
the child. Because an infant’s external canal
is short and straight, pull the pinna down and
back.
Ears

40.  Hearing acuity. In the infant, test hearing acuity by noting
the reaction to noise. Stand approximately 12 inches from
the infant and create a loud noise (e.g., clap hands,
shake/squeeze a noisy toy). Routine newborn hearing
screening is performed in most newborn nurseries 24–48
hours after birth or prior to discharge.
Ears

41. Mouth, Throat,
Nose, And
Sinuses

42. Mouth, Throat, Nose, And Sinuses
 Inspect mouth and throat. Note the condition of the lips,
palates, tongue, and buccal mucosa.
 Observe the condition of the gums. When teeth appear,
coteeth and note location.
 Inspect nose and sinuses. To inspect the nose and sinuses,
avoid using the nasal speculum in infants and young
children. Instead, push up the tip of the nose and shine the
light into each nostril. Observe the structure and patency
of the nares, discharge, tenderness, and any color or
swelling of the turbinates.

43. Breast and
Heart

44.  Inspect and palpate breasts.
Note shape, symmetry, color,
tenderness, discharge, lesions,
and masses. Newborns may
have enlarged and engorged
breasts with a white liquid
discharge resulting from the
influence of maternal
hormones
Breast and Heart

45.  Auscultate heart sounds. Listen to the heart. Note rate
and rhythm of apical impulse, S1, S2, extra heart
sounds, and murmurs. Keep in mind that sinus
arrhythmia is normal in infants. Heart sounds are
louder, higher pitched, and of shorter duration in
infants. A split S2 at the apex occurs normally in some
infants and S3 is a normal heart sound in some
children. A venous hum also may be normally heard in
children.
Breast and Heart

46. Abdomen

47.  Inspect the shape of the abdomen.
 Inspect umbilicus. Note color, discharge,
evident herniation of the umbilicus. A
bulge at the umbilicus suggests an
umbilical hernia, which may be seen in
newborns; many disappear by the age of
1 year.
 Palpate for masses and tenderness.
Palpate abdomen for softness or
hardness.
Abdomen

48.  Palpate spleen. Palpate the spleen the same as you would
for adults. Spleen tip may be palpable during inspiration. The
spleen is difficult to palpate in the newborn.
 Palpate kidneys. Palpate the kidneys the same as you would
for adults. The tip of the right kidney may be palpable during
inspiration.
 Palpate bladder. Palpate the bladder the same as you would
for adults. Bladder may be slightly palpable in infants and
small children.
Abdomen

49. Male and
Female
Genitalia

50. Male Genitalia
 Inspect penis and urinary meatus. Inspect
the genitalia, observing size for age and
any lesions. Penis is normal size for age,
and no lesions are seen. Diaper rash,
however, is a common finding in infants
 Inspect and palpate inguinal area for
hernias. Observe for any bulge in the
inguinal area. Using your pinky finger,
palpate up the inguinal canal to the
external inguinal ring if a hernia is
suspected.

51. Female Genitalia
 Inspect external genitalia. Note labia majora, labia minora,
vaginal orifice, urinary meatus, and clitoris. Labia majora and
minora are pink and moist. Newborn’s genitalia may appear
prominent because of influence of maternal hormones. Bruises
and swelling may be caused by breech vaginal delivery.

52. Anus and
Rectum

53.  Inspect the anus. The anus should be inspected in
infants. Spread the buttocks with gloved hands; note
patency of anal opening, presence of any lesions and
fissures, and condition and color of perianal skin.
Inspect the anus. The anus should be inspected in
infants. Spread the buttocks with gloved hands; note
patency of anal opening, presence of any lesions and
fissures, and condition and color of perianal skin.
Anus and Rectum

54. That’s All Thank You!