Initial Newborn Assessment

ITCC School of Nursing Initial Newborn Assessment Clark

Textbook Picture Measurements: A. Weight

B. Length C. Head Head Circum Circumfer ferenc encee D. Chest Chest Circu Circumfe mferen rence ce E. Temperature F. Heart Ra Rate G. Resp Respir irat ator ory y Rat Ratee Skin: A. Color B. Vernix

C. Lanugo

D. Milia E. Erythe Erythema ma Toxicu Toxicum m F. Acro Acrocy cyan anos osis is G. Mottling

Normal average birth weight is 7.5lbs, but the range for a full term baby is 5.5lbs to 10lbs. Below 5.5 is a low birth weight and above 10 is termed macrosomia. Normal newborn length range: 18-22in / 46-56cm. Measured from crown of head to heal. Norma Normall newbor newborn n head head circu circumfe mferen rence ce rang range: e: 12.512.5-14. 14.5in 5in / 3232-37c 37cm m Usually HC=1/2(W) +10, should be 2cm > chest circumference. Norma Normall newbor newborn n chest chest circu circumfe mferen rence ce range range:: 12-14in 12-14in / 30-35 30-35cm cm Average: 12.5in/32cm. Measured around chest at breast buds. Normal newborn temperature range: 97.7-98.9 degrees F (axillary). Normal ne newborn he heart ra rate range: 10 100-160 bpm. Su Suggested to to count fo for 6 seconds and multiple by 10 because of fast speed of beats. Norm Normal al newb newbor orn n res respi pira rato tory ry rate rate is 30-6 30-60 0 bre breat athe hes/ s/mi min. n. Coun Countt for for full full minute Check skin integrity, noting texture, dryness, or moisture. Consistent with ethnic background, pink-tinged. “Cottage Ch Cheese” White cheesy protective co covering on skin of fetus. Examine amount, and observe for creases where it can hide in. Fine, downy hair usually noticeable on shoulders, back, forehead, and cheeks.

Infant observations 8lbs 6oz

20 in 14 in 14 in 98.7 150 bpm 58/min

Smooth, intact Pink-tinged Thick, present on whole body Balding areas, present thin on legs, shoulder, lower back Exposed sebaceous glands that appear as white raised spots on the face. Present on nose, around mouth Small Small rash rash of of yell yellow ow to white white colore colored d papu papules les surro surround unded ed by redde reddened ned Not Observed skin, benign and harmless, will resolve on own. Blui Bluish sh tint tint or disc discol olor orat atio ion n to to the the dis dista tall ext extre remi miti ties es (han (hands ds and/ and/or or feet feet)) Obse Observ rved ed init initia iall lly, y, on feet feet Appearance of lacy type pattern caused by dilation of the blood vessels Not Observed


H. Jaundice I. Desquamation

under the skin. Skin appears yellow Peeling skin

J. Turgor Should not tent, bounce back immediately, sign of hydration K. Mongolian spots

May be mistaken as bruising. Black, blue, or bluish-gray pigmentation in areas on the dorsal or buttock areas. Usually fade within 1-2 yoa.

Not Observed Not Observed Good turgor, skin did not tent, bounced back immediately Not Observed

Abnormal Skin:

A. Cyanosis

A dull blue dusky coloration to the skin or mucous membranes caused by low oxygenation to the tissue in the area.

B. Petechiae

Pinpoint red or purplish dots caused by bleeding under the skin from broken blood vessels. Semicircular red marks or possibly superficial scraps on the cheeks or head. Yellow coloring of skin treated as disease entity. Occurs 24 hours after birth and is the result of excessive destruction of RBC. Total bilirubin higher than 12 mg/dl in full-term infant, and greater than 15 mg/dl in pre-term infant. Phototherapy used for treatment. A birthmark. Appears initially as flat pink spot or area on the skin and may become red, or purplish as the newborn ages. Abnormal buildup of blood vessels in the skin or organs. 30% are present at birth but can show up within the first few months after birth. S/S= red to reddish purple lesion on the skin (Strawberry spot), or a massive raised tumor with blood vessels. Most are noticed on face and neck. Birthmark that is light tan in color. Can be raised, flat, textured, smooth, or include hair. Can be located anywhere on the body and

C. Forceps Marks D. Pathologic Jaundice

E. Port wine stain F. Hemangioma

G. Café Au Lait Spots

Only acrocyanosis. Noted on feet initially after delivery Not Observed Not Observed Not Observed

Not Observed Not Observed

Not Observed


range in sizes. Head: A. Relationship to body

Head appears larger than body; ¼ length of body

B. Relationship to Chest

Head circumference is smaller than chest

C. Fontanels (anterior and posterior)

“Soft spots” between bones of the skull Anterior: 2-3cm, 3-4cm long, closes on average within 1 year. Posterior: 1-2cm may be almost closed at birth, but closes fully within 6-8 weeks. Oblong shaped appearance to the baby’s head caused by the unconnected bones in the scalp adjusting to allow for delivery down the smaller birth canal. Results from trauma during delivery with a vertex presentation. The trauma results in blood and serum accumulation in the tissues over the suture lines of the scalp below the skin but above the skull. S/S= edematous tissue over suture lines of the scalp, can demonstrate no symptoms. Swelling will subside on its own and is not painful to the infant. Collection of blood between the periosteum and the bone of the skull itself. Can appear on one or both sides of the head. “Mickey mouse ears” May not be present at birth but develops within 24-48 hours following birth. Signs and symptoms might be swelling of the head in that localized area, discoloration of tissue due to blood under surface, and they have clear edges that end at the sutures lines. Shape: Pinna should be upright with no noting of bending of cartilage. Placement: Well-formed notch of ear should be on straight line with outer canthus of eye. Cartilage: Should be flexible Hearing: Should respond to loud noises (startle reflex)

D. Molding

E. Caput Succedaneum

F. Cephalhematoma

G. Ears (Shape, placement, cartilage, hearing)

Appeared larger than body. Greater than ½ length of body. Approximately the same circumference in, in. Both were soft and flat. Very small and close-toclose approximation. No molding noted, delivered through cesarean section. Not Observed

Not Observed

Cartilage firm, and in line with eyes. Ears were flexible and bounced back when folded. Responded to noises, and had startle


reflex present. H. Eyes (color, tears, Note the size, symmetry, color, and movement of the eyes, as well as Brown in color and movement, ophthalmia exterior structures and spacing between the eyes: symmetrical. No tears Color: Clear blue/slate-gray or brown, the lens of the eye is normally neonatorum, sclera present. Jerky eye hemorrhage) not visible white or gray spots could indicate cataracts. Black and white movements, was looking speckling of the iris is an indicator of down’s syndrome. around. No sclera Pupils should be equal and reactive to light, blink reflex should be hemorrhage or opthalmia present, and sclera should be bluish white. Eyelids should be smooth neonatal observed. without drooping or malposition. Tears: Tear ducts begin to function at about 2 months. Movement: Bright objects and faces should illicit staring when infant is alert with ability to follow objects or faces with their eyes. Should be able to look up, down, side, side, and all around. Ophthalmia neonatorum: - Neonatal conjunctivitis – swelling or inflammation noted on eyelids of newborn. Can be caused by blocked duct or viral or bacterial infections. S/S= drainage from eyes that develops 1 day – 2 weeks after delivery, red, tender, puffy eyelids, or watery, bloody, or thick pus-like discharge from infants eyes. Sclera hemorrhage: small broken capillaries seen in the sclera, which should disappear within a few weeks. May notice a red spot or blotch and should not cause pain to infant or affect vision. I. Mouth (mucous Mouth should be symmetrical when infant cries, uvula should be Symetrical mouth with membranes, Epstein’s midline, with hard palate intact, and reflexes present. Tongue should regards to shape and pearls, tongue-thrush, not protrude. movement. Uvula is Mucous membranes: Intact, pink, and moist. clefts-lip, palate) midline, hard palate is Epstein’s pearls: white small specks, or inclusion cysts on gum ridges. intact, and reflexes are Tongue-thrush: small white sports/milk curd/cottage cheese appearance present. Tongue, gums, and on tongue caused by yeast that can be encountered when coming down mucous membranes are vaginal canal. pink, smooth, moist, and Cleft’s lip and palate: With cleft lip, look for symmetry noting any intact. Tongue moves abnormalities, and checking reflexes. Cleft palate: palates are whole freely, and little saliva is


with no holes or abnormalities. Insert gloved finger into baby’s mouth and feel upward for any breaks or discontinuances in palate. Sucking reflex should be present. Abnormal Head: A. Nose (Shape)

B. Choanal atresia

C. Hydrocephaly

D. Microcephaly

E. Anencephaly

F. Facial Palsy

Normal is: Flat bridge, with patent nares bilaterally, no discharge, may sneeze to clear nostrils.

noted. No thrush or Epstein pearls notes.

Normal, 2 patent nares, flat bridge, no discharge, sneezed a couple of times. Abnormal is flaring nostrils signaling respiratory distress. No flaring with respiration noted. Narrowing or blockage of nasal airway by tissue. Can affect one or Not Observed, blocked both sides. Bilateral may need resuscitation upon delivery and cyanosis each nare individually and can be noted due to breathing problems. S/S = cyanosis, breathing did not notice any difficulty if not crying (since they are nose breathers and breath through abnormalities or difficulties mouth when crying), chest retraction if not crying or breathing through in breathing. mouth, unable to nurse and breath at same time, inability to pass catheter through effected side into throat, persistent nasal discharge or blockage on affected side(s). Abnormal collection of CSF in ventricles of the brain, and is commonly Not Observed a companion with spina bifida. Signs and symptoms may include: An abnormally large head (most common), vomiting, sleepiness, irritability, seizures, and an inability to look upwards. Neurological condition when head of infant is much smaller than that Not Observed of others of same demographics. S/S= much smaller head, forehead sloping backwards, large ears, and visual impairment. Absence of a large part of the brain and skull. S/S= absence of the Not Observed skull, absence of the brain (cerebral hemispheres and cerebellum), facial feature abnormalities, and heart defects. Facial nerve paralysis caused by inflammation, damage, or swelling to Not Observed the cranial nerve in that area. S/S= facial asymmetry, inability to close eyes, nasolabial fold flattening, inability to move lips on affected side, inability to create suction around nipple when feeding causing a


drooling of milk from paralyzed side of mouth. May not be apparent at birth or for the first couple of days, and should spontaneously resolve within 10 days but may take couple weeks or months to resolve. Neck: A. (Shape and movement)

Chest: A. Normal Shape

B. Breast tissue

Abnormal Chest: A. Diaphragmatic Hernia

B. Esophageal atresia

C. Engorged Breasts

Shape: short, symmetrical. Check for trachea shifts, or mass in neck, noting swollen glands. Movement: Should be no neck stiffness, or decreased ROM. Should be freely moveable and have tonic neck reflex.

Short, symmetrical with no swelling apparent visually or when palpated. Neck moves freely with no stiffness or decreased ROM. Tonic neck reflex present.

Barrel shaped chest with bilateral expansion with inspirations. Clavicles should be straight and intact. PMI lateral to midclavicular line at 3rd or 4th intercostals space.

Barreled shaped with bilateral expansion during inspiration. Both clavicles were intact and straight. Breast tissue normal and not engorged. Breast buds were 3mm in size.

Should not note engorgement (but if you do it can be normal from hormonal exposure). Nipples should be symmetrical, may have a white discharge or supernumerany nipples noted on chest surface.

An abnormal opening in the diaphragm that allows abdominal cavity Not Observed organs to protrude into the thoracic cavity crowding the lungs. Lung tissue on the affected side does not fully develop causing respiratory problems. Breathing difficulty usually occurs right after birth and can cause atelectasis. S/S= atelectasis, cyanosis, tachypnea, tachycardia, irregular chest movements, absent breath sounds on affected side, hear bowel sounds in chest cavity; abdomen feels less full on palpation. Esophagus does not develop fully. S/S= cyanosis with attempted Not Observed feedings, or coughing, chocking, or gagging when trying to feed, excessive drooling, poor feeding or intake. Usually due to exposure to maternal hormones in the womb, and should Not Observed, not


subside within first couple weeks of life. Enlarged breast buds and females may leak colostrum. D. Fractured Clavicle

Abdomen:

A. Shape B. Umbilical Cord

Fracture of collarbone common in difficult deliveries. Assess for bruising and deformity, decreased or limited ROM of affected side, drooping appearance of extremity, creptius over affected bone, and absence of Moro reflex on affected side. Should be soft, with some laxness to muscles, and move with respirations. Domed-shaped. Should have two arteries and one vein. Will appear white and gelatinous, and should be clamped with no foul odor.

engorged, breast buds were 3mm, with absence of colostrum. Not Observed, intact symmetrical movement.

Flat, soft, moves with respirations. Domed-shaped 2 arteries and 1 vein present. White and gelatinous in color, smooth, clamped with no odor.

C. Bowel sounds Abnormal Abdomen: A. Distension:

Should be present when relaxed. Abdomen distended, appears full, may be hard when palpated.

No distention noted.

B. Imperforate Anus

Opening to anus is absent of blocked. S/S= anal opening in girls very close to vagina, newborn does not pass stool within 48 hours of delivery, missing or moved opening to anus, swollen belly area, stool passes out vagina, base of penis, scrotum, or urethra. Thickened meconium that becomes obstructive in the ileus. Will not pass stool, may have distended abdomen, non-present bowel sounds.

Not Observed

Labia minor may have vernix caseosa present and smegma in creases. Labia majora normally cover labia minor and the clitoris. Pseudomenstration (blood-tinged mucous) may be present due to maternal hormonal exposure.

Vernix caseosa present. Labia majora larger than and covering minor and clitoris. Slight edema

C. Meconium Ileus

Genitalia: (complete female and male) A. Female (labia, clitoris, meatus, edema, pseudo-menstruation)

Not Observed


Meatus: Visible, correct placement.

B. Mal penis, scrotum, erugae, phimosis, testes circumcision, edema)

B. Anus Abnormal Genitalia: A. Hermaphrodism B. Hypospadias C. Epispadias D. Cryptorchidism E. Hydrocele

Hips: A. Hips (normal, congenital hip, Barlow’s test, Ortolani’s test)

Testes descended into scrotum Scrotum pendulous and covered with rugae. Penis with urinary meatus at the tip of glans on ventral surface of penile shaft. Circumcision: monitor for edema, or discoloration, baby can go home after urinates for first time following with no problems. Performed at varies stages and ages dependent upon culture or beliefs. Patent, well placed, may have meconium stool present.

Presence of both male and female reproductive organs. Urethral opening located on the underside of the penis. Urethral opening located on the top of the penis. Undescended testes. Abnormal fluid collection within the layers of the tunica vaginalis surrounding the testis. May be unilateral or bilateral. S/S= Swelling of the testes, unequal testes size, pain and tenderness of the testes. Normal : Stable with no clicks or snaps upon movement. Congenital hip: Dysplagia- abnormal development of hip present at birth. Barlow’s test: Positive when a snap is felt as the femur leaves the acetabulum when legs are adducted over hips. Ortolani’s test: Positive when a click is felt as the femur enters the acetabulum when the hip joint is abducted and lifted.

present from maternal hormones. No pseudomenstration noted. Meatus was present in correct anatomical location. N/A

Patent. No meconium present. Not Observed N/A N/A N/A N/A N/A

Normal development of hip with no indication of dysplagia. Negative Barlow and Ortolani’s tests.

Surgery within 48 hours to close the opening to decrease the risk for infection and prevent spinal cord damage. Spine: A. Normal Appearance


Spine straight and flexible may have small dimple at the base of the spine without any connection to the spine.

Straight and flexible without indentation.

Portions of the brain and meninges protrude into the sac. Usually experiences neurological dysfunction. S/S= mental retardation, paralysis, hydrocephalus. Occulta: Incomplete closure without the spinal cord or meninges protruding. Doesn’t usually experience neurological dysfunction, but there might be bowel or bladder disturbances or weakness in the foot. S/S= tuft of hair in the lumbar or sacral area, depression in the lumbar or sacral area, hemangioma in the lumbar or sacral area. Will need surgery. Cystica: Incomplete closure with the spinal cord and meninges protruding into the sac. Sac contains CSF and the meninges. Usually doesn’t experience neurological defects. Presence of sac is the s/s. Should lay newborn on side to protect and prevent pressure on the sac, while keeping it covered with sterile dressing soaked in warm sterile saline in anticipation for surgery. The sac contains the spinal cord, CSF, and meninges. Experiences neurological dysfunction. S/S= presence of sac, bowel or bladder incontinence, hydrocephalus, spastic paralysis, club foot, knee contractures, curvature of the spine, Arnold-Chiari malformation. An abnormal pocket originating in the skin, usually located near the tailbone at the cleft of the buttocks. Can be harmless unless becomes infected, then is very painful.

Not Observed, skin intact.

Extremities: A. Symmetry

Should be equal in length with symmetrical movement.

B. Range of motion

Very flexible and should be equal on both sides of body.

Symmetrical in length, strength, and movement. Very flexible and equal

Abnormal Spine: A. Encephalocele

B. Spina Bifida

C. Meningocele

D. Myelomeningocele

E. Pilonidal Cyst






C. Muscle tone

Normal, hypertrophy, hypotrophy.

D. Number of Digits (hands and feet)

Hands: Should have total of 10 fingers, 5 fingers on each hand, with normal palmar creases and nails present that are smooth and flexible. Feet: Should have total of 10 toes, with 5 toes on each foot.

Abnormal Extremities: A. Brachial Plexus

B. Polydactyly C. Syndactyly D. Clubfoot

Reflexes: A. Rooting

B. Sucking

ROM on both sides. Strong resistance force. Normal muscle tone, strong, solid, resistance and force. 5 fingers present on each hand for total of 10 fingers. 5 toes present on each foot for total of 1o toes.

Damage to C5 or C6 cervical roots of the brachial plexus will result in Not observed the infant unable to move the upper arms, or an asymmetric Moro response. Has more than five fingers or toes. Bone does not usually grown or fuse Not observed and the extra tissue will be removed. Hereditary. “Webbed feet or hands”. Fusion of two or more fingers or toes. Not observed Usually a clubfoot twists the top of the foot downward and inward, Not observed increasing the arch and turning the heel inward. The calf muscles in the affected leg may be underdeveloped, and the affected foot may be up to 1 centimeter shorter than the other foot. Stroke or touch the corner of the newborn’s mouth. The infant should turn their head and their mouth to follow in the direction of the stimulation. Helps the baby find the breast or nipple to begin feeding.

Observed, the infant would follow the finger that was touching near her mouth in an attempt to latch on. Touch the roof of the baby’s mouth and they should start sucking. Does Observed, she had a very not develop until 32 nd week of pregnancy and not fully developed until strong sucking reflex around 36th week, so pre-term infants may have a problem sucking. present almost immediately, sucking on the fingers of dad and examiners as well as


sucking on a nipple to drink the dextrose water and on the maternal nipple for feeding. Observed, baby was able to swallow dextrose water without complication. Observed occasionally when a finger was put in the baby’s mouth, she would stick her tongue outward. Not observed, was able to swallow with no complications. Not observed

C. Swallowing

Liquid/food/substance goes down the esophagus with ease and with absence of gagging, chocking, or aspiration.

D. Extrusion

When touch the tongue the baby should push the tongue outward. Normal reflex used to project solid foods or objects out of the baby’s mouth.

E. Gagging

Done due to obstruction of throat/airway by foreign objects, mucous, liquids, etc.

F. Coughing

Done to clear throat. *Cough, Cough*

G. Sneezing

Done to clear nostrils. A sneeze is a sneeze *Achoo, “god bless you”*

H. Yawning

A sign of tiredness, opening of mouth and sucking in of air.

I. Hiccough/Hiccup

A spasm of the diaphragm that causes inhalation of air which is stopped Not observed when the glottis closes which causes the *Hiccough* sound.

J. Blink

Stimulated by light puff of air and the infant should blink both eyes.

K. Moro (startle)

Usually occurs when a baby is startled. In response to a loud sound the infant should throw their head backwards, extend extremities outwards,

Sneezed a couple of times throughout examination. Not observed

Observed. Would blink eyes when motions across face area were done that created a stream of air or startled her. Observed. When startled she would extended her


L. Grasp (Palmar)

M. Grasp (plantar)

N. Babinski

O. Tonic Neck

P. Stepping (dancing) Elimination: A. Stool (color, consistency, amount)

cry, and bring their extremities back in. Present for around 5-6 months extremities bring them in after birth. and cry. Only lasts a couple months after birth and is more prevalent in pre-term Observed. She would grasp infants. Stroke the palm of the newborn’s hand and they should coil objects (fingers) when their fingers into a grasp around the stroking object. placed in or touched the hand; she would coil fingers around the object. Toes should coil down or grasp an object when the sole of their foot is Observed. When you stroked. stroked her foot, she would coil her toes inward. Normal reflex up to about 2 years of age. When the sole of the first is Observed. Stroked the sole stroked the infant’s toes should fan out. of her feet and the toes fanned outward. Lasts about 6-7 months. “Fencing position”. When the neck of the Observed she performed infant is turned one direction the arm on the side the head is turned this reflex multiple times towards stretches outwards and the opposite arm bends up at the elbow. during examination. When holding the infant upright and placing the soles on a flat surface Observed the baby appears to be steeping or dancing. Color: Initially a blackish color “meconium” Consistency: Thick, sticky Amount: Small amount initially may be present or may pass meconium stool. 3-4 soiled diapers a day for good nutrition.

Not observed

Color: yellow, clear. Amount: should produce 6-10 wet diapers a day for good hydration.

Not observed

Cry: A. Normal cry

Strong, non-distended

B. Abnormal cry

Shrill, distressed

Observed throughout the examination. Not Observed

B. Urine (color, amount)

ITCC School of Nursing Initial Newborn Assessment Clark Sleep Patterns: A. Sleep pattern (amount 1st week)

Feeding: A. (Stomach capacity, regurgitation)

B. Bottle Feeding (how often)

C. Breast Feeding (how often)

Newborns require a lot of sleep and sleep typically 14 to 18 hours a day Not observed, she was during the first week, but don’t usually stay asleep for longer than 2 to awake for the time that I 4 hours at a time. spent with her. Upon presenting her to the mother she was initiated into breastfeeding. Stomach capacity: Day 1: about 5-7 mL, stomach does not stretch to accommodate more. Day 3: about 0.75-1 oz. Day 7: about 1.5-2 oz. Regurgitation: “Throw-up” white in substance from milk, occurs when there has been too much introduced into the stomach, as the stomach does not stretch to accommodate extra amounts. On demand, by monitoring hungry cues, but should make sure the baby is eating every 2-3 hours for the first few weeks of life and consuming about 16-24 ounces per day. Know baby is taking in a sufficient amount by number of wet diapers produced a day (6-10).

On demand, by monitoring hungry cues, but should make sure the baby is eating every 2-3 hours for the first few weeks of life. Nursing should occur 8-12 times a day. Know baby is taking in a sufficient amount by number of wet diapers produced a day (6-10).

Any item left blank will be scored as incorrect. Use N/A for not applicable (male or female specific item),

She consumed a few mL of dextrose water and initiated breastfeeding but I was not present to observe how much or how long she feed for. There was no regurgitation noted. N/A – She is breastfeeding but did consume a few mL of dextrose water that was given to her because glucose of 49 was obtained after delivery. She was initiating feeding upon presentation to mother, but I did not observe how often she was feeding.


Use “observed” or “not observed” for all items related to the infant assessed. If present, please be descriptive. References Hogan, M. A., Glazebrook, R., Brancato, V., & Rodgers, J. (2007). The normal newborn experience. In Maternalnewborn nursing: Reviews & rationals (2nd ed., pp. 268-277). Upper Saddle River, NJ: Pearson Education. (Original work published 2003) Johnson, J. Y. (2010). Newborn care. In Demystified: Maternal-newborn nursing (pp. 246-255). New York, NY: McGraw-Hill.

Initial Newborn Assessment

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