NUR 161
NEWBORN NURSING ASSESSMENT GUIDE
OBSERVATION
Vital Signs
A. Respiration
"NORMALS"
Rate-normally 30-50/minute; quite shallow,
irregular.
Breathing usually abdominal or diaphragmatic.
Transient tachypnea.
Breath sound may be difficult to localize - clear
to rales & rhonchi.
B. Pulse
Beat heard 5th intercostal space. May hear
murmurs first or second day which may be
physiologic. After this time, notify physician.
120-150 beats/min (if asleep, 80-90/min; if
crying, up to 180/min).
HOW TO ELICIT
Observe first, while infant is
quiet.
Check for quality and
quantity. Count for at least
30 seconds.
Check breath sounds for
rales & rhonchi.
Auscultate with stethoscope
while infant quiet. Note
quality and position, rate
and rhythm.
Auscultate for one full
minute.
DEVIATIONS
Less than 35 or +50 (tachypnea) when at rest,
dyspnea or cyanosis. Grunting. "Periodic
breathing" of more than 10 seconds without a
respiration is classified as apnea.
Respiratory Distress Symptoms are retractions,
grunting nasal flaring.
Less than 100-bradycardia, would indicate
More than 150-trachycardia, distress
Trends are as important as any single finding.
Note a shift in placement of heart sounds.
(could be due to tension pneumothorax.)
Weak pulse
Arrhythmia
May be regular or irregular, strong, pulses equal
C. Blood Pressure
D. Temperature
Normal average 80/40 at birth to 100/50 by 10
days; depends on age and weight of infant.
Difficult to obtain diastolic pressure with
standard sphygmomanometer - Blood pressures
not routinely done on normal newborns - only
those who are premature, in distress or suspected
of having an anomaly.
Rectal 36.5-37.2o C(97.7-99oF) Axillary 36.537.2o C(97.7-98.6oF)
Temperature stabilizes within 8-12 hours after
delivery.
Check strength and equality
of apical femoral, and
brachial pulses.
Doppler method.
Decreased or absent femoral pulses indicate
coarctation of aorta.
Rectal temperature initially
and axillary temperatures
the remaining time.
Swings of more than 2oF from one reading to
next.
Hypothermia extremely stressful and
dangerous in newborn.
Skin temperature is an earlier and more
sensitive indicator of thermal state than core
temperature.
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Low blood pressure (shock, hypovolemia)
Weight
Average birth weight about 7 pounds 8 oz. (3405
Gm)
Males usually weigh slightly more than females,
white babies more than non-white, second more
than first.
Average physiologic weight loss about 5-10% of
birth weight.
Warmed, padded accurate
safe scale optimal.
Daily comparisons of
weight.
Length
Average-50 cm (20 inches) both sexes grow 1
inch per month for the first 6 months.
4. Head
Large in comparison to rest of body; 1/4 of body
size.
Circumference about 33-35 cm. and is
approximately 2 cm greater than chest
circumference, (although the first day they may
equal due to molding)
Asymmetrical due to molding (result of pressure
during birth)
May see bruising due to trauma of delivery;
-Caput succedaneum-swelling or
edema of scalp near presenting
portion; crosses suture lines
-Cephalhematoma-soft mass of
irreductible blood accumulating,
between periosteum and flat skull
bone-absorbed in 2-3 weeks, does
not cross suture lines.
Place flat on back and
extend to fullest.
Use disposable paper tape
measure.
For accurate measurement
paper measuring tape is
placed over the most
prominent part of the
occiput and brought to just
above the eyebrows.
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Overheating may cause hyperventilation and
stress and apnea.
Hypothermia may indicate sepsis, chilling.
Less than 2500 grams - Low birth weight (not
premature).
Using the "Newborn Classification and
Neonatal Mortality Risk" chart (Lubchenco),
infants classed as large for Gestational Age,
appropriate for Gestational Age, or Small for
Gestational Age (IGA, AGA, SGA) by plotting
their birthweight against their gestational age.
Infants of Diabetic mothers are classically
large for Gestational Age.
Cradle cap
Microcephaly - mental deficiency.
Hydrocephalus - increased cerebral spinal fluid
from various causes - yields increased
intracranial pressure
Macrocephaly may be a sign.
Craniostenosis - premature closure of the
cranial sutures before or shortly after birth.
A. Fontanels
(openings at the
points of union
of the skull
bones)
1. Anterior
2. Posterior
B. Scalp/hair
C. Face provides
examiner an
opportunity to
indicate unusual
facies.
D. Eyes
E. Ears
Feel soft
Useful indicator of infant's condition.
May pulsate with heartbeat
Overriding suture lines due to molding and will
disappear when molding disappears
Diamond shaped, average diameter
1.5-2.5 cm.
Closes at about one year of age.
Triangular shape; may be nearly closed at birth
Measured in centimeters
Bulging fontanele - a clue to increased
palpated gently
intracranial pressure
Examine when infant at rest. Depressed fontanele - indicates dehydration.
Junction of 2 parietal and 2
frontal bones.
Located between occipital
and parietal bones.
Small, minute "pin-prick" in scalp due to internal Palpate gently.
fetal monitor scalp electrode varying amounts of Note color, amount &
hair.
texture.
Note placement and symmetry of eyes, ears &
During cry, note symmetry
grimace with cry.
of facial muscles.
Chin recessed.
Usually blue or slate blue-gray in color.
Will open spontaneously.
Sclera may have bluish tint.
Subconjunctival hemorrhage not uncommon. Iris
color may change up to 3 months. Pupils
reactive to light and equal. Tearing not
established until 1-3 months. Incoordinate
movements normal. Transient strabismus due to
poor neuromuscular control of eye muscles.
Eyelids edema due to instillation of silver nitrate
in eyes--chemical conjunctivitis 1-2 hours after
instillation; disappears in 1-2 days. Can
discriminate patterns, brightness; will track
moving objects to midline.
Epicanthal folds in oriental babies.
Have well formed cartilage (one determinant of
gestational age). Pinna inserted on head on
horizontal plane to outer canthus of eye.
Place infant in vertical
position away from light.
Check for pupil size,
reaction of pupils to light,
blink reflex to light, and
edema and inflammation of
eyelids.
Note shape of eyes.
Note color of eyes and
sclera.
Check vision
Note eye ball movement
Check eyelids
Should return quickly when
folded over. Inspect shape,
size and position, and
evaluate hearing by his
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May have abrasions or bruising with
instrument deliveries.
Asymmetry may be due to nerve damage.
Chromosomal anomalies.
Lacerations to cheek – especially in C section
Babies or Forceps Delivery
Retrolental Fibroplasia may result from
hyperoxemia;
Opacities on pupil (sign of congenital
cataract).
Setting sun sign - may indicate increased
intracranial pressure if persists. Report
immediately to prevent eye damage.
Infectious conjunctivitis - same symptoms as
chemical conjunctivitis, but caused by staph or
gram negative rods. Onset usually after 2nd
day. Requires treatment.
Epicanthal folds (Down's syndrome)
Pupils not reactive and/or equal.
Misplacement may indicate chromosomal
problem (low set ears).
Malformation may indicate associated renal
problems.
Can hear immediately after birth.
response to loud noises.
F. Nose
Small and narrow, symmetrical.
Infants obligatory nose breathers.
Sneezing normal.
Milia
Patent nares bilaterally.
Does not open mouth to breath.
G. Mouth
Fat pads on cheeks.
Sucking callouses on lips for a few weeks.
Lips should be pink.
Precocious teeth will be pulled, especially if
loose to prevent aspiration. Inclusion cysts
(gray-white lesions)
Epstein's Pearls (white cysts that are hard);
disappear in a few weeks. Tongue proportional
to mouth.
Assess for mucus
obstructions.
Pass soft catheter (not to be
done by student RN's)
OR
Gently cover infants mouth
and occlude one nare at a
time & observe if infant has
any signs of respiratory
distress.
Check by inserting gloved
finger or by stimulating
infant to cry.
5. Neck
Short and creased with deep moist folds.
Posterior neck lacks loose extra folds of skin.
Observe crying, sucking.
Palpate carefully.
Passive range of motion.
Clavicles straight and intact.
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Pressure necrosis.
Preauricular skin tags - usually tied off and
allowed to slough off.
Choanal atresia.
Nasal flaring - indicates distress.
Drooling-suspect tracheo-esophageal fistula.
Cleft palate, cleft lip
Macroglossia (large tongue)
Thrush-white curd type deposits; difficult to
remove, bleed when disrupted-caused by
candida albicans.
Frenum linguae - "tongue tied" ridge of
frenulum tissue attached to underside of
tongue, causing a heartshape at tip of tongue.
Clipping of tongue no longer done due to
danger of infection.
Nerve paralysis from birth trauma-asymmetrical mouth movements.
Fracture clavicle
Swelling or masses
Rigidity of neck may indicate
sternocleidomastoid injury.
Torticollis or wry neck (head held at angle).
Webbing
Abnormally short neck.
Arching of neck.
6. Chest
7. Abdomen
8. Extremities
A. Arms and
hands
Cylindrical shape, circumference
No intracostal, subcostal or suprasternal
retractions.
Small bell stethoscope.
Individual stethoscope at
each bedside.
Funnel check (lower sternum depressed),
Pigeon breast (prominent sternum and costal
cartilage).
Diaphragm and abdominal muscles perform
most of breathing.
Xiphoid cartilage - protrusion at lower end of
sternum.
Breast tissue diameter 5 cm. or more at term.
Engorged breasts: "witchs' milk"
Extra or supernumerary nipples-below and
medial to true nipples.
Cylindrical with some protrusion. Distention
after feeding common. Umbilical cord stumpWhartons jelly. (2 arteries, 1 vein)
Nontender.
No cyanosis and few, if any, blood vessels,
should be seen.
Circumference
Bowel sounds heard shortly after birth.
Bladder 1-4 cm above symphysis; empties about
3 hours after birth; urine mild odor.
Measure circumference.
Measure breast tissue.
Palpate xiphoid.
Observe respiratory effort.
Respiratory Distress symptoms:
- retractions
- grunting
- nasal flaring
Asymmetry of chest may indicate
pneumothorax.
Gently palpate all 4
quadrants.
Check contour.
Check for masses,
distention.
Check for bladder
distention.
Check for any hernias.
Check vessels in cord.
Check abdominal tension
Listen for bowel sounds
Arms are abducted, flexed and internally rotated.
Movement symmetrical. Hands are normally
clenched into fists. Full range of motion
possible. Five fingers - each hand & separate.
Note symmetry of
movement
Open hands and examine
each finger separately;
count them.
Passive range of motion to
all joints.
Meconium or yellow stained cord-evidence of
fetal distress.
Single umbilical artery - associated anomalies
(renal).
Diaphragmatic hernia - abdomen flat and
scaphoid.
Congenital tumors - do not palpate abdomen.
Omphalocele
Urachal fistula
Umbilical hernia, infections
Atonic bladder myelomeningocele-crade
Distention not associated with feeding (may be
first sign of many GI abnormalities).
Foul smelling drainage from umbilicus;
bleeding from umbilicus, inflammation.
Absence of bowel sounds.
Unusual position may be caused by fracture
(humerus, elbow).
Poor muscle tone may be due to cerebral
injury, narcosis, shock, anoxia.
Syndactyly (webbing). Polydactyly (excess
digits)
Simian crease-s single palmar crease
(frequently present in infants with Down's
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Syndrome.)
Brachial Palsy-paralysis of portions of arm trauma to brachial plexus during delivery.
Erb-Duchenne paralysis-arm lies limply at
side; elbow in extension with forearm
B. Legs and feet
9. Back
10. Genital
(Assess last)
A. Male
Legs of equal length and symmetrical thigh and
gluteal skin folds.
Legs flexed, in partial abduction. Femoral and
pedal pulses present. No resistance to hip
abduction. Hips abduct to more than 60o. Legs
shorter than arms at birth. Creases on soles of
feet. Foot is in straight line. Positional clubfootbased on position in utero.
5 toes each foot, separate
Spine is straight and flat.
Coccygeal dimple - note if hair present or
appears very deep. Dimple common finding
resulting from maldevelopment of caudal
ligament. At least 1/2 of back devoid of lanugo.
Urine of either may be brick red in color due to
uric acid crystals. Diaper will hematest negative.
Phimosis (opening of prepuce is narrowed and
foreskin cannot be retraced over gland); normal
size varies.
Testicles descended at 40 weeks; not
consistently found in scrotum.
Meatus is at tip of penis.
Scrotal edema/discoloration common in breech
deliveries.
Hydrocele-very common in newborns
Circumcision - optional.
Passive range of motion to
all joints.
Check symmetry, thigh
folds. Check amount of
sole creases
Place infant in prone
position and separate
buttocks to expose
coccygeal area. Check
vertebral alignment.
Palpate scrotal sac.
Examine penis for
placement of meatus.
Assess scrotal rugae
Palpate testes
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pronated. Moro reflex can't be elicited on
affected side (5th and 6th cervical nerve palsy).
Unilateral or bilateral dislocated hips.
Absence of pulses in lower extremities, classic
sign of coarctation of aorta. Syndactyly and
polydactyly
Genu recurvatum-knee bends backwards.
Clubfoot (talipes equinovarus).
Meningomyelocele, spina bifida.
Dermal sinus tract - site of potential
contamination of cerebral spinal fluid
Pilonidal cysts.
Curvatures of vertebral column.
Hypospadias. Epispadias
Hernia
Abrasions resulting from breech presentation
Specific Gravity normally 1.003-1.012
Undescended testicles.
B. Female
1. Anus
2. Skin
A. Color
Labia majora covers labia minora (an indicator
of gestational age).
May have hymenal tag-disappears in several
weeks.
May have blood or white discharge pseudomenses
Edema and bruising in breech delivery.
Patent
Passage of meconium usually within 24 hours.
Normal stool cycle;
Meconium stool-black, sticky, odorless
Transitational stool - green/black
Breast/bottle stool - yellow
Frequency of stools depend on method of
feeding (breast vs. bottle)
Pink and warm to the touch, red when crying.
Acrocyanosis (blue extremities) common in first
24 hours of life.
Blood supply returns quickly when skin
blanched with a finger.
Mottling-common with chilling; can be sign of
distress.
Common skin manifestations:
Milia-tiny pearl white bumps occurring around
nose, check, forehead.
Mongolian spots - hyper-pigmented brownbluish spots over lower back. Usually found in
dark skinned races. "Stork's" beak mark-reddish
areas on eyelids & occiput caused by dilatation
of superficial blood vessels.
Erythema Toxicum-newborn rash "flea-bite"
-areas of redness varying in diameter with small
raised yellowish white wheal.
Peak incidence: 24-48o of life.
Forcep marks.
Recto-vaginal fistual, recto-anthral.
Check patency by observing Imperforate anus
passing of meconium or soft Rectal stress
catheter inserted gently.
No stool after 24o of life.
Check color and consistency
of stools
Blanch tip of nose or gum
line to assess jaundice.
Check capillary refill on
palm.
Examine skin on nose, back
& buttocks.
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Acrocyanosis persisting beyond 24-48 hours of
life.
Circumoral cyanosis (blue around mouth).
Mottling.
Meconium stained skin indicates fetal distress
pre- or intra- partum.
Observe for jaundice (1/2 of all newborn
within first 3 days of life).
Jaundice in the first 24 hours is not normal.
Ecchymosis (bruises) may cause an elevated
bilirubin as they resolve. "Bronze baby
syndrome"-seen rarely if phototherapy is used
with an obstructive type jaundice.
"Physiologic" jaundice may appear from day
3-7. Plethora after the initial period may
indicate polycythemia. Watch any laceration
(especially C-section or fetal scalp electrode)
for bleeding, infection.
Pallor
B. Texture
C. Turgor
13. Reflexes
A. Grasp
B. Root
Soft; may have dry & peeling hands & feet
Vernix caseosa (cheesy white substance and
lanugo (fine, downy hair) disappear after a few
days.
First day - may be slight edematous.
Subcutaneous fat.
Both hands and feet. Strong enough in hands to
enable infant to be lifted (carefully) off bed.
Turns head toward stimuli and attempts sucking.
C. Suck
Tongue should not be up while feeding-prevent
flow of milk.
D. Startle or
Moro
Arms and legs extend upward with any
disturbance in equilibrium. "C" shape in fingers.
Present at birth.
E. Tonic Neck
Fencing position - when on back with head
turned to side, tends to flex arm and legs and
extend arm and leg looking toward.
Hyperextension of all toes when one side of sole
is stroked from heel upward across ball of foot.
F. Babinski
G. Stepping
General
Activity/Appearance
Check creases for vernix
Large amounts of lanugo (premature)
Generalized cracked or peeling skin
(postmaturity).
Gently pinch up skin over
abdomen. If skin returns
promptly to surface, turgor
is elastic. If feels doughy
and stays pinched up,
tenting is present.
Pressure against palm or
sole of foot.
Touch against cheek or
chin.
Do when hungry.
Stimulus to lips.
Poor turgor may indicate dehydration.
Decreased serum protein will cause edema.
Sclerema (hardening of subcutaneous tissue) poor prognostic sign.
Low birth weight or postmature baby may lack
subcutaneous tissue.
Asymmetry of response.
Loud noise, grasp both
hands, lift until arms fully
extended and suddenly
release.
Postural relax.
Poor sucking or easily fatigued. Suck and
swallow not coordinated before 34 weeks
gestation. Excessive drooling may indicate
TEF.
Sudden or startling behavior may indicate
neurological symptoms. Asymmetry of body
response. Absence of Moro.
Asymmetry.
Stroke bottom of foot.
Absence.
When held upright and one
foot touching a flat surface,
will step alternately.
Asymmetry.
Cry strong and lusty.
Sleeps in fetal position.
Responds to stimulation
Alternate periods of excitability and quietness.
Cries vary in length from 3-7 minutes after
Cry-weak or high pitched, shrill or absent cry.
Abnormal movements (seizures)
Lethargic, limp
Hypertonic
Floppy baby
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consoling measures are used. Cry strong.
Symmetrical movement and strength in all
extremities
May be jerky or have brief twitching.
Head lag not over 45o
Tremors
Revised 1/16
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