Normal Newborn: General Appearance
[email protected] Well-flexed, full range of motion, spontaneous movement Common variations Legs extended with frank breech Signs of potential distress or deviations from expected findings Posture limp Asymmetry of movement Persistent tremor, twitching Vital Signs Temperature - range 36.5 to 37 axillary Common variations Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery Signs of potential distress or deviations from expected findings Temperature is not reliable indicator of infection A temperature less than 36.5 Heart rate - range 120 to 160 beats per minute Common variations Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying Signs of potential distress or deviations from expected findings Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound Respiration - range 30 to 60 breaths per minute Common variations Bilateral bronchial breath sounds Moist breath sounds may be present shortly after birth Signs of potential distress or deviations from expected findings Asymmetrical chest movements Apnea >15 seconds Diminished breath sounds
Seesaw respirations Grunting Nasal flaring Retractions Deep sighing Tachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor Blood pressure - not done routinely Factors to consider Varies with change in activity level Appropriate cuff size important for accurate reading Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities Sign of potential distress or deviations from expected findings Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta General Measurements Head circumference - 33 to 35 cm Expected findings Head should be 2 to 3 cms larger than the chest Chest circumference - 30.5 to 33 cm Common variations Molding of head may result in a lower head circumference measurement Head and chest circumference may be equal for the first 24 to 48 hours of life Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.) Length range - 48 to 53 cms (19 - 21 inches)
Skin Expected findings Skin reddish in color, smooth and puffy at birth
At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals Vernix caseosa Lanugo Turgor good with quick recoil Hair silky and soft with individual strands Nipples present and in expected locations Cord with one vein and two arteries Cord clamp tight and cord drying Nails to end of fingers and often extend slightly beyond Common variations Acrocyanosis - result of sluggish peripheral circulation
Mongolian spots in infants of African-American descent
Mottling
Physiologic jaundice
Milia
Erythema toxicum
Petechiae/ bruises over presenting part Skin tags usually around ears or digits (tied off) Harlequin color change
Signs of potential distress or deviations from normal findings Jaundice within 24 hours of birth General cyanosis Circumoral cyanosis between feedings Petechiae or ecchymoses other than on presenting part All rashes with exception of erythema toxicum Pigmented nevi Yellow vernix Hemangioma Pallor Forceps marks
Head Expected findings Anterior fontanel diamond shaped 2-3 - 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat Sutures palpable with small separation between each
Common variations Caput succedaneum
Molding of fontanels and suture spaces
Signs of potential distress or deviations from normal findings Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalhematoma
Closed sutures
Eyes Expected findings Slate gray or blue eye color No tears Fixation at times - with ability to follow objects to midline Red reflex Blink reflex Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light
Common variations Edematous eyelids
Uncoordinated movements
May focus for a few seconds
Signs of potential distress or deviations from expected findings Discharges Chemical conjunctivitis
Opaque lenses Absence of Red Reflex Epicanthal folds in newborns not of Oriental descent "Doll's eyes" beyond 10 days of age Reflexes absent Subconjunctival hemorrhage
Expected findings Pinna top on horizontal line with outer canthus of eye
Loud noise elicits Startle Reflex Flexible pinna with cartilage present
Common variations Skin tags on or around ears
Signs of potential distress or deviations from expected findings Ear placement low Preauricular sinus
Clefts present Malformations Cartilage absent
Nose Expected findings Nostrils patent bilaterally Obligate nose breathers No nasal discharge
Common variations Sneezes to clear nostrils Bridge appears absent Thin white nasal mucus discharge
Signs of potential distress or deviations from expected findings Choanal atresia and discharge Malformation Nasal flaring beyond first few moments after birth
Mouth and Throat Expected findings Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.
Palate high arched
Uvula midline Minimal or absent salivation Tongue moves freely and does not protrude Well developed fat pads bilateral cheeks Sucking reflex
Rooting reflex Gag reflex Extrusion reflex
Common variations Epstein's pearls on ridges of gums
Signs of potential distress or deviations from expected findings Cleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete Protruding tongue Candida Albicans
Diminished tongue movement Percocious teeth
Neck Expected findings Short and thick Turns easily side to side Clavicles intact Tonic neck reflex present Neck-righting reflex present Some head control
Signs of potential distress or deviations from expected findings Torticollis-stiff neck drawing head to one side Resistance to flexion Webbing of neck Large fat pad on back of neck Palpable crepitus, movement with palpation of clavicle
Chest
Expected findings Evident xiphoid process Equal anteroposterior and lateral diameter Bilateral synchronous chest movement Symmetrical nipples
Common variations "Witch's milk" Enlarged breasts Accessory nipples
Signs of potential distress or deviations from expected findings Asymmetrical chest movements Sternum depressed Marked retractions Absent breast tissue Flattened chest Supernumerary nipples Nipples widely spaced Bowel sounds auscultated
Abdomen
Expected findings Dome-shaped abdomen Abdominal respirations Soft to palpation Well formed umbilical cord Three vessels in cord Cord dry at base Liver papable 2 - 3 cms below right costal margin Bilaterally equal femoral pulses Bowel sounds auscultated within two hours of birth Voiding within 24 hours of birth Meconium within 24 - 48 hours of birth
Common variations Small umbilical hernia
Signs of potential distress or deviations from expected findings Bowel sounds absent Peristaltic waves visible Abdominal distention Palpable masses Scaphoid-shaped abdomen Omphalocele Base of cord with redness or drainage Cord with two vessels
Female Genitalia Expected findings Edematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia
Common variations Hymenal tag Pseudomenstruation Smegma Increased pigmentation
Ecchymosis and edema after breech birth "Red brick" pink-stained urine due to uric acid crystals
Signs of potential distress or deviations from expected findings Labia fused Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia
Male Genitalia Expected findings Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voiding
Common variations Prepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech delivery
Signs of potential distress or deviations from expected findings Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia
Back and Rectum
Expected findings Intact spine without masses or openings Trunk incurvature reflex Patent anal opening "Wink reflex" present
Signs of potential distress or deviations from expected findings
Limitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cystExtremities Expected findings Maintains posture of flexion Equal and bilateral movement and tone Full range of motion all joints Ten fingers and ten toes Legs appear bowed Feet appear flat
Palmar creases present
Sole creases present
Negative hip click Grasp reflex present
Signs of potential distress or deviations from expected findings Unequal tone Asymmetrical movement of extremities Polydactyly
Syndactyly Unequal leg length Asymmetrical skin creases posterior thigh
Dislocation of hip
Simean crease Persistent cyanosis of nail beds Marked metatarus varus
Neuromuscular System Expected findings Maintains postion of flexion When prone, turns head side to side Holds head and back in horizontal plane when held prone Ability to hold head momentarily erect
Signs of potential distress or deviations from expected findings Hypotonia Quivering
Limp extremities or straightening of extremities Clonic jerking Paralysis
