Newborn Assessment Study Guide



MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY

Maternal Infant Nursing 316

Newborn Assessment Study Guide

Upon completion of this study guide, the student will be able to:

1. Identify the assessment criteria for each component of the physical assessment of the newborn.

2. Discuss the significance of the assessment findings for a normal newborn.

3. Identify and distinguish between variations in the six (6) physical characteristics and six (6) neuromuscular characteristics used to determine gestational age of the neonate using the Ballard Gestational Age Assessment Tool.

4. Identify a minimum of eight (8) reflexes exhibited by the newborn.

5. Correctly identify the infant as appropriate, small, or large for gestational age based on the scoring tool findings (Ballard Assessment).

Directions:

1. View the videotapes "Physical Assessment of the Newborn" and "Gestational Age Assessment" on the library’s 2ndfloor reserve Media Resource Center under Lynn Kennell’s name. [DVD 1883 2 parts]

2. Use the attached assessment guide to make notes on both the "Quiet Exam" and the "Head-to-Toe Sequence" while viewing the "Physical Assessment" tape.

Use the Ballard Gestational Assessment and Growth Chart in your text and complete the worksheet while viewing the "Gestational Age Assessment" tape.

3. Refer to your texts for further clarification and reference:

Hockenberry et al: Ch 8 pages 228-258 (9th ed.)

Davidson, et al: pages 819-860 (9th ed.)

Evaluation:

1. An online objective quiz on Blackboard will be taken by each student on a date to be announced. This test will be worth 25 points of your total CTE Points.

2. During the maternity rotation, you will complete a newborn physical assessment and gestational assessment and include it with the Patient-Client Assessment Form when you are assigned to the nursery.

Terminology for Physical Assessment of the Newborn

Acrocyanosis - A bluish discoloration of the hands and feet due to sluggish peripheral circulation.

Barlow's maneuver - A procedure to rule out congenital hip instability; flexion of the legs, abduction of the hips to approximately 90 degrees, then downward pressure is exerted while adducting the thighs. A positive sign is palpable dislocation during the maneuver.

Caput succedaneum - A collection of fluid in the soft tissues of the scalp that may override the suture lines.

Caused by pressure on the presenting part of the head against the cervix during labor.

Cephalohematoma - A collection of blood between the periosteum and the cranial bone (usually the parietal bone) appearing as unilateral or bilateral and limited to the suture lines of the affected bone(s). A result of the extravasation of ruptured blood vessels from the pressure of birth.

Diastasis recti - Gap between abdominal recti muscles.

Epstein pearls - Small, white, round epithelial cysts on the hard palate and along the gum margins.

Erythema neonatorum toxicum - "Newborn rash" or flea bite rash. A generalized rash characterized by red,

elevated papules appearing around 24-48 hours of age. Resolves without treatment.

Fontanelle - "Soft spot". An area of fibrous tissue over the juncture of the cranial bones.

Lanugo - Fine downy hair of varying distribution covering the body with exception of the palms of the hands and soles of the feet.

Milia - White, pinpoint papules on the chin and/or nose resulting from unopened sebaceous glands.

Molding - Shaping of the head caused by overriding of the cranial bones to facilitate movement through the birth canal.

Mongolian spots - "Oriental patches". An area of bluish-black pigmenta-tion over the buttocks and the lower back, commonly seen in non-Caucasian races.

Mottling - Discoloration of the skin in irregular areas resembling a lace-like pattern.

Occipital-frontal circumference (OFC) - The greatest circumference of the head, i.e., over the supraorbital ridges and the occipital prominence.

Ortolani's maneuver - A procedure to rule out congenital hip dislocation: flexion of the legs, abduction of the hips to approximately 90 degrees, then forward pressure from behind the greater trochanter while the thigh is abducted. A positive finding is a "click", which is palpable as the dislocation is reduced.

Pseudomenstruation - White or blood-tinged mucous discharge from the vaginal secondary to the withdrawal

of maternal hormones.

Rugae - Folds of tissue over the scrotum that allow for expansion of the tissue.

Subconjunctival hemorrhage - An area of bleeding on the sclera due to changes in vascular tension during birth.

Telangiectatic nevi - "Stork bites" or capillary hemangiomas. A flat area of capillary dilatation appearing as

small clusters of pink-red spots on the nose, nape of the neck, lower occipital bone, and eyelids, which blanch easily.

Vernix caseosa - A white cheese-like substance covering the body,

particularly noticeable in the creases of the skin.

MENNONITE COLLEGE OF NURSING at ILLINOIS STATE UNIVERSITY

Parent Child Nursing - 323

Reflexes in the Neonate

(See text for more reflexes)

|REFLEX |STIMULUS |RESPONSE |SEEN |NOT SEEN |

|Moro |Infant lying on back, slightly |Arms extended, head thrown back, |Birth |4 months |

| |raised head suddenly released; |fingers fat out; arms brought back | | |

| |infant lowered abruptly |to center with hands clenched; legs| | |

| | |extended | | |

|Rooting |Lightly stroke cheek with finger |Head turns toward stimulus |Birth |4 months |

|Sucking |Insert finger into infant's mouth |Rhythmic sucking |Birth |7 months |

|Startle |Loud noise |Similar to Moro response |Birth |4 months |

|Palmar (grasp) |Touch palm with finger or object |Grasp object, holds tightly |Birth |6 months |

|Tonic neck (fencing) |Head turned to one side while |Arm and leg extend on the side |2 months |6 months |

| |infant lies on back |infant faces. Opposite arm and leg | | |

| | |extend. | | |

|Blinking |Light flash |Eyelids close |Birth | ----- |

|Stepping |Infant supported in an upright |Rhythmic stepping movements |Birth |6 weeks |

| |position with feet touching flat | | | |

| |surface. | | | |

|Babinski |Stroke the sole of foot from heel |Toes fan out |Birth |12 mo. |

| |to toe laterally | | | |

*This assessment guide follows the videotape. The systematic approach makes key assessments while the baby is quiet, then moves into a head-to-toe sequence. Reflexes are integrated with the appropriate systems.

QUIET EXAM

|Component |Assessment Criteria |Normal Findings |Common Variations |

|Posture |Posture |Hands clenched, Flexion, adduction of |Front breech may have extended legs and|

| | |extremities |abducted thighs |

|Vital Signs: |Axillary: 36.5 - 37oC | | |

|Temperature |(97.7 - 98.6oF) | | |

| Pulse 120-160 |Rate |120-160 beats/minute |Varies with body temperature, period of|

|beats/minute Varies with body | | |reactivity, physical activity |

|temperature, period of | | |During sleep, as low as 100bpm; with |

|reactivity, physical activity |Quality |Strong |crying, as high as 180bpm |

| | | | |

| | | | |

| |Rhythm |Regular |Often visible |

| | | |Apex of heart is at PMI in neonate |

| |Heart Sounds |PMI: 4th-5th intercostal space left of | |

| | |midclavicular line |Transient murmurs secondary to |

| | | |incomplete closure of ductus arteriosus|

| | | |or foramen ovale |

| | |Listen over entire precardium | |

| Respirations |Rate |30-60 breaths/minute |Varies with body temperature, period of|

| | | |reactivity, physical activity |

| | | | |

| |Quality |Relaxed, synchronized movement of the | |

| | |chest and abdomen | |

| | | | |

| | |Irregular—Assess for full minute | |

| |Rhythm | | |

| | |Bronchovesicular sounds with | |

| | |inspiration, expiration equal in |Sibilant and sonorous wheezes in |

| |Breath Sounds |duration |immediate post delivery period |

| Blood Pressure | |Systolic: 54-92 in males | |

| | |Diastolic: 38-72 in males | |

| | | | |

| | |Systolic: 46-84 in females | |

| | |Diastolic: 38-72 in females | |

|Bowel Sounds |Location |Present in all 4 quadrants |Bowel sounds may be absent during first|

| | | |period of reactivity. |

|Skin |Color |Caucasian: ruddy or pink- |Mottling |

| | |tinged |Acrocyanosis |

| | |Non-caucasian: consistent |Telangiectatic nevi |

| | |with racial background |Mongolian spots |

| | | |Jaundice may occur after |

| | | |24 hours |

| | | |Ecchymosis or localized |

| | | |petechiae from birth |

| | | |trauma |

| | | |Harlequin coloring |

| | | |Plethora |

| | | | |

| |Texture |Soft, smooth, thin |Milia |

| | | |Mongolian spots |

| | | |Telangiectatic nevi |

| | | |Jaundice—significant if |

| | | |> 24hrs old |

| | | |Birthmarks: |

| | | |nevus flammeus— |

| | | |portwine stain |

| | | |strawberry hemangioma |

| | | |cavernous hemangioma |

| | | |café au lait spots |

| |Turgor |Elastic | |

| | | | |

| |Mucous membranes |Pink & moist | |

| | | | |

|Measurements |Head |33—-33.5 cm (13-14- in.) | |

| | | | |

| |Chest |30.5 – 33 cm (12 – 13 in.) | |

| | | | |

| |Length |44 –53 cm (17.5 – 21 in) | |

Worksheet for Complications of the

Physical Assessment of the Newborn

Certain parameters are considered "abnormal" and need to be recognized early by the nurse. Use your texts to define and identify the significance of the following.

Head: Hydrocephaly

Microcephaly

Anencephaly

Forceps marks/abrasions/scalp electrode site

Eyes: Wide set eyes

Epicanthal folds

Conjunctivitis

Chemical conjunctivitis

Ears: Low set ears

Mouth: Extrusion of tongue

Chest: Abnormal respirations:

retractions

flaring nares

expiratory grunting

Abdomen: Umbilicus: if foul-smelling or discharge present

Back: Pilonidal sinus

Tuft of hair at base of spine

Male Genitalia:

Hydrocele

Congenital phimosis

Hypospadias/epispadias

Extremities:

Hands:

Simian crease

polydactyly

syndactyly

Feet:

positional deformity

club feet

Neurological:

Cry: Lusty

high-pitched

weak

Worksheet for Videotape on

Gestational Age Assessment

( Refer to Olds as well as video)

Characteristic What to Look for and/or Do

Skin

Lanugo

Plantar Creases

Breast

Ear

Genitals (male)

Genitals (female)

Posture

Square Window

Arm Recoil

Popliteal Angle

Scarf Sign

Heel-to-Ear

Definition of Terms

Premature: Refers to an infant born after 20 weeks of gestation and before 38 weeks of gestation.

Postmature: Refers to an infant born after 42 weeks of gestation.

Small for Gestational Age: Refers to an infant whose length, head circumference, and weight fall at or below the tenth percentile for all babies at that gestational age.

Large for Gestational Age: Refers to an infant whose length, head circumference, and weight fall at or above the 90th percentile for all babies at that gestational age.

Appropriate for Gestational Age: A determination that the infant falls between the tenth and 90th percentile for all babies at that gestational age.

Predictable Problems Based on Gestational Age

Premature: Small for Gestational Age:

Respiratory Distress Syndrome Hypothermia

Hypothermia Hypoglycemia

Hypoglycemia Aspiration Syndrome

Infection Birth asphyxia

Apnea Polycythemia

Hypocalcemia Intrauterine infection

Hyperbilirubinemia Problems related to the

Intracranial hemorrhage etiology of the infant's

poor growth

Postmature:

Large for Gestational Age:

Birth asphyxia

Aspiration Syndrome Hypoglycemia

Hypoglycemia Birth trauma

Polycythemia

Small for Gestational Age

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