This document provides an overview of assessing and caring for normal newborns. It discusses physiological adaptation after birth including respiratory, cardiovascular, thermoregulation and more. It also covers initial assessment using APGAR scoring, transitional assessment during periods of reactivity, and a full physical examination from head to toe. Key aspects include establishing independent breathing, circulation changes, temperature regulation challenges, and developmental immaturity of various organ systems in the first days of life. Ongoing monitoring of vital signs and growth measurements are also emphasized.

1. UNIT 6
ASSESSESSMENT & MANAGEMENT OF
NORMAL NEONATES
By
Dr. Anu Joykutty

2. TOPICS
Normal Neonate
– Physiological adaptation,
– Initial & Daily assessment
– Essential newborn care, Thermal
control,
– Breast feeding, prevention of infections
– Immunization
• Minor disorders of newborn and its
management
• Levels of Neonatal care (level I, II, & III)
• At primary, secondary and tertiary levels
• Maintenance of Repots and Records

3. A healthy infant born at term b/w 38-42
wks should have average birth wt, cries
immediately following birth, establishes
independent rhythmic respiration & quickly
adapts to the changed environment.
HEALTHY NEWBORN

4. PHYSIOLOGICAL ADAPTATION
RESPIRATORY ADAPTATION
• Initial breathing is probably the result of a reflex triggered by pressure
changes, chilling, noise, light and other sensations related to the birth
process.
Process:
• The initial entry of air into the lungs is opposed by the surface tension
of the fluid in fetal lungs and alveoli.
• The fetal lung fluid is removed by the pulmonary capillaries and
lymphatic vessels & also removed during the normal forces of labour
and delivery.
• As the chest emerges from the birth canal, fluid is squeezed from the
lungs through the nose and mouth.
• After complete emergence of the neonates chest, a brisk recoil of the
thorax occurs.
• Air enters the upper airway to replace the lost fluid.

5. • In most cases an exaggerated respiratory reaction
follows within 1 minute of birth, and the infant takes the
first gasping breath and cries.
• Following the period of reactivity and after respirations
are established, respirations are shallow and irregular,
ranging from 30 to 60 breaths per minute
• Neonatal respiratory function is largely a matter of
diaphragmatic contraction.
• The ribs of the infant articulate with the spine at a
horizontal rather than a downward slope; consequently
the rib cage cannot expand with inspiration as readily as
an adults.
• The newborn infants chest and abdomen rise
simultaneously with inspiration.

7. CARDIOVASCULAR ADAPTATION
• Fetal circulation ceases, and extrauterine circulation
begins.
• Ductus arteriosus: Within the last 12 hrs of extra
uterine life the shunt between the pulmonary
artery and the aorta, constricts but anatomic
closure takes more time; approximately 80% of
these ducts are closed by the end of the third
month
• Ductus venosus (vessel connecting the umbilical
vein and inferior vena cava) constricts within 3 to 7
days of birth.

8. Foramen ovale
1st cry causes 1st breath that inflates the lungs
Pulmonary vascular resistance , blood flow & pulmonary
artery pressure decreases in right side
Right atrium pressure decreases
But Pulmonary blood flow & pressure in left side of heart
increases
Pressure difference in both sides of heart
Closure of foramen ovale

9. Hematopoietic system
• Hemoglobin concentration : 14 to 29 g/dl,
• Hematocrit : 43% to 63%
• The RBC count : 5.7 to 5.8 per mm
• WBC count : 10.000 to 30.000 per mm3 is normal at
birth. It increases to about 23,000 to 24,000 per
mm3 during the first day after birth. Normally
11,500 per mm3 is maintained during the neonatal
period
• Platelet count : 200,000 and 300,000 per mm3
• Cord blood samples may be used to identify the
infants blood type and Rh status.

10. Thermoregulation
Heat production: the infant produces only two thirds
as much heat as an adult but loses twice as much
heat per unit area.
• Large body surface area is partially compensated by
the newborns usual position of flexion, which
decreases the amount of surface area exposed to
the environment.
• Subcutaneous fat : thin layer of s/c fat conserve
body heat
• Non shivering thermogenesis production of heat is
through metabolism of brown fat and by increased
metabolic activity in the brain, heart, and liver.

11. Heat loss : in the newborn occurs in four ways:
• Conduction: the loss of heat from the body surface to
cooler surfaces in direct contact. When admitted to the
nursery, the newborn is placed in a warmed crib to
minimize heat loss.
• Convection: the flow of heat from the body surface to
cooler ambient air. so ambient temperatures are kept at
240 C and newborns are wrapped to protect them from
the cold.
• Radiation: the loss of heat from the body surface to
cooler solid surfaces not in direct contact but in relative
proximity to each other. So the cribs and examining
tables are placed away from outside windows.
• Evaporation: the loss of heat that occurs when a liquid is
converted to a vapour. Evaporation occurs as a result of
vaporization of moisture from the skin and is intensified
by failure to dry the newborn directly after birth

13. FLUID & ELECTROLYTE IMBALANCE
• about 4o% of body weight of newborn is ECF
• Each day the newborn takes in and excrete roughly 600 to 700
ml of water which is 20% of total body fluid
• The GFR of a newborn is 30 to 50% of adults
• The decrease ability to excrete excessive sodium result in
hypotonic urine compared with plasma.
• There is a higher concentration of sodium, phosphate,
chloride, organic acid and lower concentration of bi
carbonate ion
• Loss of fluid through urine, feces, lungs , increased metabolic
rate and internal fluid intake results in a 5% to 10% loss of the
birth weight which occurs over the first 3 to 5 days of life.
• The neonate should regain birth weight within 10 days.
• Stool water loss is estimated at 5 to 10 ml/kg/day.

14. Renal system
• Position: kidneys occupy a large portion of the
posterior abdominal wall & bladder lies close to the
anterior abdominal wall
• Volume: at birth 40ml will be in bladder. A term
infants void 15 to 60 ml of urine per kg/day
• Colour: cloudy(1st voiding),normally straw-coloured
and odorless, Sometimes pink-tinged uric crystals
present.
• Specific gravity :1.005 to 1.015.
• Frequency : 2 to 6 times during the 1st and 2nd days
of life and from 5 to 25 times during the subsequent
24 hours..

15. GASTROINTESTINAL SYSTEM
• The full term newborn is capable of swallowing, digesting,
metabolizing, absorbing proteins and simple
carbohydrates, and emulsifying fats.
• the mucus membrane of the mouth is pink and moist. The
hard and soft palate are intact. Small whitish area (Epstein
pearls.) may be found on the gum margin and at the
junction of hard and soft palate. The cheeks are full.
• Sucking behaviour is influenced by neuromuscular
maturity
• newborn coordinates the breathing, sucking and
swallowing reflexes necessary for oral feeding.
• Peristaltic activities in the esophagus is uncoordinated in
the first few days of life.
• Teeth begin developing in utero with enamel formation
continuing until about 10 years.

16. • Normal colonic bacteria are established within the
first week after birth. The normal intestine flora
help synthesize vitamin K, folic acid and biotin.
• Bowel sounds can usually be heard shortly after
birth. Stomach capacity varies from 30 to 90 ml,
depending on size of the infant.
• The stomach empties intermittently, beginning a
few minutes after the start of a feed and emptying
2 to 4 hours after feeding. The cardiac sphincter and
nervous control of the stomach are immature, so
some regurgitation may occur
• The infants ability to digest carbohydrates, fats and
proteins is regulated by the presence of certain
enzymes.

18. Changs in Stooling Patterns of
Newborns
MECONIUM
• Infant's first stool; composed of amniotic fluid and its constituents,
intestinal secretions, shed mucosal cells, and possibly blood (ingested
maternal blood or minor bleeding of alimentary tract vessels).
• Passage of meconium should occur within the first 24 to 48 hours,
although it may be delayed up to 7 days in very low-birth-weight infants.
TRANSITIONAL STOOLS
• Usually appear by third day after initiation of feeding; greenish brown to
yellowish brown, thin, and less sticky than meconium; may contain some
milk curds.
MILK STOOL
• Usually appears by fourth day.
• In breastfed infants, stools are yellow to golden, are pasty in consistency,
and have an odor similar to that of sour milk.
• In formula-fed infants, stools are pale yellow to light brown, are firmer in
consistency, and have a more offensive odor.

19. MUSCULOSKELETAL CHANGES
• Bones ossification is not complete
• Muscles development is complete
• Moulding occurs during the labour.
• Neonate have 2 fontanelle: anterior and
posterior

20. IMMUNOLOGICAL CHANGES
• 3 main immunoglobins present are:
IgG(crosses placenta and gives immunity to
some viral infections),IgA & IgM (do not cross
placenta)
• Passive immunity is caused by breast milk ie
colostrums.

21. REPRODUCTIVE SYSTEM CHANGES
• Ovaries and primordial cells are present in
females
• No spermatogenesis started in male until
puberty.
• Breast engorgement and milk secretion occur in
males and females due to withdrawal of
maternal hormones.
• Pseudo-menstruation occur in females

22. NEUROLOGICAL CHANGES
• This system is also not fully developed
• Brain growth occur after birth
• If not started then temperature instability and
uncoordinate muscle movements occurs.
• The reflexes are:
• Blink, corneal, rooting, palmar grasp, traction,
tonic neck, moro, stepping, plantar grasp,
babinski .

23. NEWBORN ASSESSMENT
Initial assessment with APGAR scoring.
Transitional assessment during the periods of
reactivity.
Physical assessment – head to foot assessment

24. STAGES OF NEWBORN ASSESSMENT
INITIAL ASSESSMENT WITH APGAR SCORE
• The most frequently used method to assess the
newborns immediate adjustment to extra uterine
life is the APGAR scoring system.
• It was developed by Virginia Apgar in 1952. the
score is based on observation of heart rate,
respiratory effort, muscle tone, reflex irritability
and colour.
• Each item is given a score of 0,1 or 2.
• APGAR scoring is done at 1 min and 5 min after
birth and is repeated every 5 minutes until the
infants condition stabilizes

25. APGAR scoring
SIGN 0 1 2
MUSCLE TONE
(A)
Flaccid/limp Some flexion of
extremities
Active movements/well
flexed
HEART RATE
(P)
Absent Slow,<100 >100
REFLEXES (G) No response Grimace Cry, sneeze
COLOUR (A) Blue, pale Body pink,
extremities blue
Completely pink
RESPIRATORY
EFFORT (R)
Absent Slow ,irregular,
weak cry
Good crying
TOTAL Severe depression(0-
3)
Mild depression
(4-7)
No depression (7-10)
INTERPRETATION
0-3: Severe distress/ asphyxia.
4-6: Moderate distress.
7-10: indicates absence of difficulty in adjusting to extrauterine life.
APGAR score is affected by the degree of physiologic immaturity, infection, congenital
malformations, maternal sedation or analgesia and neuromuscular disorders

26. TRANSITIONAL ASSESSMENT DURING THE PERIODS OF
REACTIVITY
• Immediate after birth neonate tries to cope up with the extra uterine environment.
• Newborn during the first 24 hours gets various changes in the vital function such as heart rate, respiration,
motor activity, color and bowel activity, these changes occur in an orderly manner. It is known as period of
reactivity
FIRST PERIOD OF REACTIVITY
• After birth during first 6-8 hours the newborn passes through the first period of reactivity. During first 30
minutes of period of reactivity the neonate is alert, active cries and has a strong sucking reflex.
• It is a good time for breast feeding and eye to eye contact with mother.
• Respiratory rate is over 60 beats per minute.
• Heart rate is 160 beats per minute.
• Bowel sound are heard and mucus secretions are increased.
• Exposure to the environment should be avoided to maintain the vital signs.
SECOND PERIOD OF REACTIVITY
• It starts when neonates awakes from the first deep sleep.
• It is about 6-8 hours after birth. It lasts for about 2-5 hours.
• In this stage child is alert, active and responsive.
• Respiratory and heart rate will slightly increase.
• Passage of meconium commonly occurs during this stage
THIRD PERIOD OF REACTIVITY
• All the vital come back to normal.
• No secretion from nose and mouth.
• Frequently child passes urine.
• Behavioral assessment should be done at this period.
• Childs and all other activities becomes normal

27. PHYSICAL ASSESSMENT – HEAD TO
FOOT ASSESSMENT
General Guidelines
• Keep warm during examination
• From general to specific
• Least disturbing first
• Document ALL abnormal findings & provide
nursing care

28. GENERAL APPEARANCE

29. Posture
• Full term:
– Symmetric
– Face turned to side
– Flexed extremities
– Hands tightly fisted with thumb covered by the fingers
• Special Concerns
• Asymmetric
– Fractured clavicle or humerus
– Nerve injuries (Paralysis)
• Breech Presentation
– Knees and legs straightened or in FROG position

30. VITAL SIGNS

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TEMPERATURE
• Site: Axillary NOT Rectal
• Duration: 3 mins
• Normal Range: 36.5 – 37.6 C
• Stabilizes within 8-12 hrs
• Monitor q 30 mins until stable for 2 hrs then q 8 hrs
Nursing Considerations
• Keep dry and well-wrapped
• Keep away from cold objects or outside walls
• Perform procedures in warm, padded surface
• Keep room temperature warm

32. Heat Loss Mechanisms
• Convection
• Conduction
• Radiation
• Evaporation
051104 Neonatal Care 32

33. 051104 Neonatal Care 33
Pulse
• Awake: 120 – 160 bpm—120 – 140 bpm
• Asleep: 90-110 bpm
• Crying: 180 bpm
• Rhythm: irregular, immaturity of cardiac regulatory center in the medulla
• Duration: 1 full minute, not crying
• Site: Apical
Nursing Considerations
• Keep warm
• Take HR for 1 full minute
• Listen for murmurs
• Palpate peripheral pulses
• Assess for cyanosis
• Observe for CP distress

34. 051104 Neonatal Care 34
Respiration
• Characteristics:
Nasal breathers, gentle, quiet, rapid BUT shallow;
may have short periods of apnea (<15 secs) and
irregular without cyanosis—periodic respirations
• Rate: 30-60 cpm
• Duration: 1 full minute
Nursing Considerations
• Position on side
• Suction PRN
• Observe for respiratory distress
• Administer oxygen via hood PRN and as prescribed

35. Blood Pressure
• NOT routinely measured UNLESS in distress or
CHD is suspected
• At birth: 80/46 mmHg*
• After birth: 65/41 mmHg*
• Using Doppler UTZ

36. ANTHROPOMETRIC
MESUREMENTS

37. 051104 Neonatal Care 37
Body Measurements
Weight:
• Average weight of an INDIAN child is 2500 gm. The baby
loses up to 10% of the birth weight in the initial 3-4 days
as it gets adjusted to the extrauterine environment, then
slowly weight is regained by tenth day of life.
– Range of weight: 2500-4300 gms (5.5 to 9.5 lbs )
– 70-75% TBW is water
– LBW = below 2500 gms; regardless of AOG

38. 051104 Neonatal Care 38
• Height/ Length:
– 45 to 55 cm (18-22 inches)
– Average:50 cm
– Techniques: using measuring tape/ Infantometer
• Supine with legs extended
–Crown to rump
–Head to heel

39. 051104 Neonatal Care 39
• Head Circumference (HC):
– 33 to 35cm (13-14 inches)
– Technique: using tape measure
• From the most prominent part of the
occiput to just above the eyebrows
– 1/3 the size of an adult’s head
– Disproportionately LARGE for its body
– HC should be = or 2cm > CC

40. 051104 Neonatal Care 40
• Chest Circumference (CC):
–30 to 33 cm (12-13 inches)
–Technique: using tape measure
• From the lower edge of the scapulas to
directly over the nipple line anteriorly
–CC should be = or < 2 cm than HC

41. Abdominal circumference
• Measure below umbilicus (not usually measured
unless specific indication)
• Abdomen enlargement after feeding because of
lax abdominal muscles Same size as chest
• Enlarging abdomen between feedings (abdominal
mass or blockage in intestinal tract)

44. SKIN COLOR
• Check colour: Inspect and palpate. Under natural light, Inspect naked newborn in well-lit, warm area
without drafts; natural daylight provides best lighting. Inspect newborn when quiet and when active
Normal evidence:
• Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia
• Generally pink
• Varying with ethnic origin, skin pigmentation beginning to deepen right after birth in basal layer of
epidermis
• Check vernix caseosa: Whitish, cheesy, odourless substance. Variations are absent (post maturity),
Excessive (prematurity), Yellow colour fetal anoxia >36 hr before birth, Rh or ABO incompatibility),
Green colour (meconium), Odour (intrauterine infection)
• Acrocyanosis-cyanosis of extremities, especially if chilled
• Mottling-Transient discoloration of skin when exposed to decreased temperature. Resulting from
vasoconstriction, lack of fat, and hypoxia
• Milia : “Baby pimples” .Pinpoint white papules on cheeks, across bridge of nose, or on chin . Caused by
plugged sebaceous glands. Requires no treatment . Disappears in a few weeks
• Birth marks:
– Mongolian spotting : Dark bruise-like places most often found on buttocks and sacrum • African-
American, Asian, Native American, or Hispanic descent • May disappear by school age
– Stork Bite (Telangiectatic Nevi) • Red spots found on back of neck, bridge of nose, and eyelids •
Usually disappear spontaneously between first and second year of life
• Physiologic jaundice -Yellow discoloration of newborn skin and sclera caused by excessive bilirubin in
the blood (greater than 5 mg/dl). Appears after 1st 24°.Peaks-days 2 to4. Common: 60% of newborns.
Usually clears up by end of first week. Assess by blanching nose or sternum .Begins in head .Determine
how far down it extends
• Erythema toxicum neonatorum is a common skin rash affecting healthy newborn babies. It is not
serious, does not cause the baby any harm and clears up without any treatment.
• Desquamation: Dryness/ peeling of the skin. Usually occurs after 24-36 hours . In post maturity

45. ACROCYANOSIS
DESQUAMATION
MILIA STORK BITE
MONGOLIAN SPOT
VERNIX CASEOSA
JAUNDICE
MOTTLING ERYTHEMA TOXICUM
NEONATORUM

46. Abnormal Variations:
• Pathologic jaundice : Jaundice appears in the first 24 hours after
birth .Total bilirubin level > 12 mg/dl
• Port Wine Stain (Nevus Flammeus): A type of vascular malformation.
Varies in type and location. Will not disappear. Becomes a darker,
more purplish colour with age
• Strawberry marks: Nevus Vasculosus or Capillary Hemangioma. Dark
red, raised lobulated tumor in head, neck trunk & extremities. Fade
after 7 to 9 years of age
• Edema on hands, feet; pitting over tibia
• Pallor: cardiovascular problem, CNS damage, blood dyscrasia, blood
loss, twin-to-twin transfusion, nosocomial infection
• Cyanosis: central (bluish skin, tongue, lips due to low oxygen,
hypothermia, infection, hypoglycemia, cardiopulmonary diseases ) &
peripheral(bluish skin, pink tongue & lips due to drugs & heredity)
• Petechiae :clotting factor deficiency, infection
• Ecchymoses :hemorrhagic disease, traumatic birth

47. PORT WINE STAIN
STRAWBERRY MARKS
ECCHYMOSES
PETECHIAE
PALLOR

48. HEAD
NORMAL FINDINGS
• Assess for symmetry, shape, swelling, movement: Soft, pliable, moves easily, with some
molding (if NVD); round & well-shaped (if CS)
• Measure HC: 33-35cm(HC = or > CC)
• Hairs: Silky, single strands lying flat; growth pattern toward face and neck
• Fontanelles: “soft spot”: anterior (5 cm diamond)& posterior(triangle, smaller than anterior).
• Sutures: Overriding or separated
• Molding: Overlapping of skull bones due to compression during labor and delivery which
disappears in few days
• Forceps Marks : U –shaped bruising usually on the cheeks after forcep delivery
• Reflex : Head lag
• Caput Succeedaneum: Swelling of soft tissues of the scalp in the presenting part, due to
pressure, crosses the suture lines, resolves 3 days after birth.
ABNORMAL FINDINGS
• HC: increased HC in hydrocephalus. Decreased HC in microcephaly.
• Hair: Fine, woolly (prematurity), Unusual swirls, patterns, hairline or coarse, brittle
(endocrine or genetic disorders)
• Fontanelles :bulging (tumor, hemorrhage, infection), Large, flat, soft (malnutrition,
hydrocephaly, retarded bone age, hypothyroidism), Depressed (dehydration),
small(hyperthyroidism, microcephaly), Craniosynostosis(premature closure of the
fontanelles)
• Sutures: Widely spaced (hydrocephaly)
• Cephalhematoma: Sub-periosteal hemorrhage with collection blood due to rupture of
capillaries as a result of trauma does not crossed suture lines resolves in several weeks

49. CAPUT SUCCEEDANEUM
MOLDING
FORCEPS MARKS
DEPRESSED & BULGING FONTANELLES HYDROCEPHALY
CEPHALHEMATOMA
CRANIOSYNOSTOSIS

50. 051104 Neonatal Care 50
FACE & EARS
Assess:
• Facial movement & symmetry
• Symmetry, size, shape and spacing of eyes,
nose and ears

51. 051104 Neonatal Care 51
EYES
• Placement: space between each eyes is one third the distance between
2 outer canthus of eyes.
• Symmetric in size, shape
• Discharge: None
• No tears. Tear formation begins @ 2-3 month
• Eyebrows: Distinct (not connected in midline)
• Eyeballs: Both present and of equal size, both round, firm
• Eyeball movement: Random, jerky, uneven, focus possible briefly,
following to midline
• Pupil: Present, equal in size, reactive to light
• Sclera color: white sclera/ Slate gray, brown or dark blue/ Final eye
color: after 6-12 months
• Reflex: Blink & Glabellar, Doll’s eye

52. 051104 Neonatal Care 52
Abnormal findings:
• (+) transient strabismus due to weak EOM
• (+) Edema on eyelids r/t pressure during delivery or
effects of medication
• Discharge: purulent(infection)
• Agenesis or absence of one or both eyeballs
• Small eyeball size (rubella syndrome)
• Pink color of iris (albinism)
• Jaundiced sclera (hyperbilirubinemia)
Nursing Considerations:
• Administer eye medication within 1 hr after birth to
prevent Ophthalmia neonatorum
• DOC: Erythromycin 0.5%
Tetracycline 1%
Silver Nitrate 1%
• From inner to outer canthus of the eye (conjunctival sac)

53. 051104 Neonatal Care 53

54. 051104 Neonatal Care 54
NOSE
Assess: Observe shape, placement, patency,
configuration of bridge of nose
• Small & narrow
• Flattened, midline
• Nasal breathers
• (+) Periodic sneezing
• Reactive to strong odors
Abnormality:
• (+) Flaring = respiratory distress
• (+) Low nasal bridge = Down’s syndrome
• Cyanosis

55. 051104 Neonatal Care 55
EARS
• Assess: Observe size, placement on head, amount
of cartilage, open auditory canal
• Soft and pliable; with firm cartilage
• Placement: Pinna should be at the level of outer
canthus of the eye
• Hearing: Responses to voice and other sounds
• Abnormality: (+) Low set ears = renal or
chromosomal abnormalities
• Prominent or protruding ears
• Deaf
• May be congested and hear well after few days

56. 051104 Neonatal Care 56
LOW SET EARS

57. 051104 Neonatal Care 57
Accessory tragus:
remnant of 1st branchial
arch
Congenital preauricular sinus:
ends blindly
risk for infection

58. 051104 Neonatal Care 58
Mouth
• Pink, moist gums
• Intact soft & hard palates
– (+) Epstein’s pearls
• Uvula midline
• Tongue moves freely, symmetrical with short
frenulum
• (+) Extrusion & Gag reflexes

59. 051104 Neonatal Care 59
• Small mouth or large tongue = chromosomal
problems
• (+) white patches on tongue or side of the
cheek = Oral thrush