Newborn Assessment 2.16

8/2/2019 Newborn Assessment 2.16

1/16

1Rev 8/11

Name: Date Grade ______________

NEWBORN ASSESSMENT

**Complete this page on your assigned baby during your nursery or postpartum rotation. Turn in the completed

newborn assessment, Ballard score, and growth chart to your clinical instructor.**

Infant's last name____Sawyer____________________________ Sex ____M____

Birthdate __________02/09/12_____________________________ Time _09:01 am_

Maternal Blood Type (MBT) ____A+_______ ABS __________ Infant Blood Type (if available) __N/A___

Maternal GBS status ______Negative__________________________ Treatment received: No

Maternal HIV status __Negative_________ If positive, received treatment during pregnancy: Yes No

GTPAL ___2-1-0-1-1_________________________ EDD (if known) ____02/01/2012___________

Prenatal care: No Date of first visit ______N/A__________ # of visits ___0___

Complications/Risk factors during pregnancy ______No Complications/No Prenatal Care______

_____________________________________________________________________________________

Length of Labor (time of delivery time of onset) 18 hours (TOD: 09:01 am TOO: 2:58 am on 02/08/12

Type of Delivery: SVD Assisted delivery: ______No____________________

Complications during delivery_________________None________________________

Blood glucose level ____________________ CRP level (if applicable) __________________________

Vitamin K (Phytonadione) time ___09:15 am__ Erythromycin eye ointment time____09:18 am____

Other medications given/ordered _________None_____________

_____________________________________________________________________________________

Time of 1st

bath___10:00 am___ Time of 1st

urine_____10:17 am______ Time of 1st

stool ___09:46 am__

Method of feeding: Formula Type of Formula___Gerber New Start_________________

Time of 1st feeding _____10:40 am____________ Average amount of feeding _____1 ounce______


2/16

2Rev 8/11

NEWBORN ASSESSMENT

**Complete textbook description BEFOREcoming to nursery and/or postpartum clinical and bring it with you.

Complete the your baby column during either of these clinical days and turn in to clinical instructor.**

MEASUREMENTS TEXTBOOK DESCRIPTION YOUR BABY

Birth weight (lbs, oz, kg, or g) 2500 4000 g

(3400-female/3500-male)

Safe amount of weight loss

(ounces AND grams)

10 % loss (34-35 g)

(0.035 ounces in a gram and

1.19-1.23 ounces)

**Do the math!!**

Length (cm or in) 45-55 cm

Measure top of head to heel

Head circumference (cm or in) 32-36.8 cm

Measure a greatest diameter

occipito-frontal circumference

Chest circumference (cm or in) < or = 30 cm (average 30-33 cm

Measure @ nipple line

VITALSIGNS TEXTBOOK YOUR BABY (MOST RECENT)

Temperature

y What is the preferredmethod of measurement?

y What is a normal newborntemperature?

y When should it stabilize?

Axillary

37 degrees C (36.5 37.2)

8-10 hours old

Apical pulse

y How long should HR becounted in newborn?

y What is the normal HR in anewborn?

1 full minute

100-160 beats/min

Listen 4th

intercostal space

Respiratory Rate

y How long should RR becounted in a newborn?

y What is the normal RR in anewborn?

1 full minute

30-60 breaths/min


3/16

3Rev 8/11

Neonatal Pain

y List 2 pain scales used forassessment of neonatal pain.

y List 3 nonpharmacologicalmethods of pain

management.

y List 3 pharmacological agentsused for neonatal pain.

NIPS Neonatal Infant Pain Scale

PIPP Premature Infant Pain

Profile

CRIES Crying, Req increased 02,

increased V/S, expression and

sleeplessness

1)containment swaddling

2)Non-nutritive sucking pacifier

3)Skin to skin contac

4)Distraction-Visual, oral,

auditory

1)Non-opiod Tylenol (mild

moderate

2)Opiod MS04 & Fentanyl &

Toradol

3)Epidural Nerve Block

4)Sweeteze

**Use NIPS scale to rate your

babys pain with assessment.**

COMMON LABS TEXTBOOK YOUR BABY

Bilirubin (serum, TcB)

y What is the normal level?y When will the level peak?

5-6 mg/dl to 12 mg/dl

60-70 hours from birth

Glucose (one touch, accucheck)

y When is it checked?y What level is hypoglycemic?y What interventions are

initiated for low levels?

Within 2-3 hours of birth

< 36 mg/dl

1)Feeding immediately

2)IV Dextrose

Newborn screeny When is it done?y List 3 disorders that can be

detected.

W

ithin 1-2 hours of birth

PKU, T4, Sickle Cell,

Galactosemia, Drug Serum

SKIN TEXTBOOK YOUR BABY

Color & temperature

Pink or acrocyanotic

T 36.5 37.0 C

Acrocyanosis

Hands and feet appear slightly

cyanotic. Intermittently over 7-

10

Mottling Condition that is marked bydiscolored areas. Looks like

lace.


4/16

4Rev 8/11

Harlequin sign

A benign transient color change

seen in neonates in which one

half of the body blanches while

the other gets redder clear

line of demarcation.

Erythema toxicum

I

nnocuous pink popularneonatal rash of unknown origin

with super imposed vesicles

appearing within 24-48 hours

spontaneously goes away.

Milia

Small white sebaceous glands

appearing as tiny white pinpoint

papules on the forehead, nose,

cheek and chin

Miliaria (see Tabers)

An inflamed popular or vesicular

rash that results in obstruction

of the flow of sweat from sweat

glands~ prickly head rash.

Patient returns to normal when

placed in a cooler environment.

Jaundice

y Definition, causes,treatments, & complications.

y Briefly differentiate betweenphysiologic & pathologic.

y List 2 possible causes ofpathologic jaundice.

y What is breastfeedingjaundice?

Yellow color of skin due to

increased level of bilirubin in

body tissues. Jaundice does not

usually appear until bilirubin

levels reach 5mg/dl. Any visible

jaundice within the 1st 24 hours

of life or persistence of jaundice

beyond 7-10 days requires

investigation.

Physiologic usually results from

destruction ofRBCs by the

immature liver at birth.

Pathologic

Hemolytic disease: hemolytic

anemia, sickle cell, auto immune

and mono

Breastfeeding P

hysiologic andresults initially from hemo

concentration due to

inadequate fluid intake. If bili

levels exceed 20 ml/dl, mother

should stop breast feeding for

24-36 hours or until levels drop.


5/16

5Rev 8/11

Mongolian Spots

Bluish, gray or dark non-

elevated pigmentation areas

usually found over the lower

back and buttocks and primarily

in non-white races

Stork bite marks

(Telangiectasia nevi)

A

vascular lesion formed bydilatation of a group of small

blood vessels. It may appear as

a birthmark.

Port wine stain

(Nevus flammeus)

A large reddish purple

discoloration of the face or neck

usually not elevated above the

skin. It is considered a

deformity due to size and color.

Tx with flash lamp laser.

Nevus vasculosus(Strawberry mark)

Superficial blood vessels are

enlarged. Usually congenital

and slightly elevated, red,

purple on face, neck, head and

arms.

Vernix caseosa

Protective gray white fatty

substance of cheesy consistency

covering of the fetal skin.

Lanugo

Fine downy hair covering the

fetus body. 1st seen at 13-16

weeks. At 20 weeks it covers

face and body. 28-30 weeks it is

at its greatest amount, but at 3rd

trimester it will disappear.HEAD AND NECK TEXTBOOK YOUR BABY

Size & position Head- 32to 36.8 cm. Measured

just above the eye brows


6/16

6Rev 8/11

Anterior fontanel

y Measurement & location.y When should it close?y What is the significance of

sunken/depressed? flat/soft?

full/bulging/tense?

The diamond shaped junction of

the coronal, frontal, sagittal

sutures.

It becomes ossified within 18

months.

Fontanels is an un-ossified

membrane or soft spot lying

between the cranial bones of

the fetus skull

1)Norm firm and turned

inward

2)Tense or bulging- fluid builds

up in brain or brain swells that

increases pressure in the brain

3)Sunken or depressed notenough fluid dehydrated or

malnutritioned.

Posterior fontanel

y Measurement & location.y When should it close?

The 3 cm x 2 cm triangular

fontanel at the junction of the

sagittal and lambdoid sutures is

ossified by 6-8 weeks after birth.

Suture lines

y Definition & function. The line union in an immovablearticulation, as those betweenthe skull bones. The skull bones

overlap at the suture lines which

permits adaptation to thevarious diameters of the

mothers pelvis. Babys head

assumes normal shape within 3

days of birth.

**Use these terms to document:

palpable, separated,

overlapping, widely spaced,

&/or closed.**

Molding Shaping of the fetal head to

adapt itself to the dimensions of

the birth canal during descent

through the pelvis.

Forcep marks Forcep injury produces linear

marks across both sides of the

face in the shape of the bladesof the forceps. Forceps help

extract head from birth canal.


7/16

7Rev 8/11

Cephalhematoma

y Definition & location.y Most common causesy Cross or does not cross

suture lines?

y Complications or specialmonitoring needed if noted

A mass composed of clotted

blood located between the

periosteum and the skull of the

newborn. It is confined

between suture lines and is

usually unilateral. A rupture

occurs of the periosteal bridging

veins due to pressure and

friction during L & D. The blood

reabsorbs gradually over a few

weeks. Swelling is limited by

the margin of the cranial bone

(usually parietal).

Caput Succedaneum

y Definition & location.y Causey Cross or does not cross

suture lines?

Diffuse edema of the fetal scalp

that crosses the suture lines.

Head compression against the

cervix impedes venous return

forcing serum into interstitialtissue. The swelling reabsorbs

within 1-3 days. Swelling of the

tissue over the presenting part

of the fetal head is caused by

pressure during labor.

EYES TEXTBOOK YOUR BABY

Placement Eyes and space between eyes

each 1/3 the distance from

outer to outer canthus.

Epicanthal folds E.F. are characteristic in some

races. However, EF can presentwith Downs syndrome.

Vision

y PERRLA?y What is the visual acuity of a

full-term newborn?

y What are the newbornsvisual preferences (color,

black & white, distance,

patterns)?

Pupils equal in size, round and

reactive to light.

Visual acuity 50 cm from

objects. Clearest 17-20 cm.

Prefer soft red light, darkened

room.

5 days of age and < they preferblack and white patterns.

NOSE TEXTBOOK YOUR BABY


8/16

8Rev 8/11

Placement Observe shape, placement,

patency and configuration

midline, nose breather, flat or

deviated.

Sneezing & nasal mucusnormal

or abnormal?

Sneezing is normal and is used

to clear nasal mucous with someor no drainage.

Choanal Atresia

y Definitiony How is it diagnosed?

Cyanosis at rest and return of

pink color with crying due to

copious drainage and blockage

of bone.

EARS TEXTBOOK YOUR BABY

Placement Line drawn through inner and

outer canthus of eyes which

reaches to the top notch of ears.

Hearing Screenwhen is it

done?

Screened by hospital discharge

to home after birth.

MOUTH TEXTBOOK YOUR BABY

Cleft lip or palate

y Brief definition.y Discuss how a newborn is

assessed for both.

Midline fissure or opening in the

lips or palate resulting from

failure of the primary palate to

fuse.

Perform visual assessment.

Facial nerve paralysis

y Define and list S/S.y Most common cause

Facial nerve injury (facial

paralysis caused by pressure on

facial nerve; often by forceps.

Absence of movement inaffected sided. Noticeable

when baby cries.

Epstein's pearls Small whitish areas found on

gum margins and juncture of the

hard and soft palate.

Thrush (Moniliasis)

y Cause & treatmenty What if breastfeeding?

Fungal infection of the mouth or

throat by the formation of white

patches on a red, moist inflamed

mucous membrane. Caused by

candida (yeast). Tx: oral

antifungal cream.S

ometimesinfant cannot breast feed.

CHEST TEXTBOOK YOUR BABY


9/16

9Rev 8/11

Nipples

y Define breast engorgementof newborns.

y DefineWitchs milk.

Engorgement is the swelling of

the breast tissue in both sexes

by the hyper-estrogen of

pregnancy. Witchs milk is the

thin discharge from the nipples.

Respiratory patterny Symmetric?y Define periodic breathing &

apnea. Are these findings

normal or abnormal?

y What are S/S of respiratorydistress?

Breaths are shallow andirregular from 30-60

breaths/min.

Periodic breathing includes

pauses in respirations lasting 60)

Breath sounds

y What is normally heard?y What may be heard at birth,

especially with C-section

delivery, and why?

Breath sounds are loud and

clear

Infant can present with crackles

and/or adventious sounds

because the secretions are being

squeezed out of the lungs as in avaginal birth.

Heart murmurs

y Normal or abnormal?y Do murmurs require follow-

up?

Heart murmurs Normal during

1st few days of life

Murmurs require f/u if there is a

murmur + poor feeding, apnea,

cyanosis or pallor.

ABDOMEN TEXTBOOK YOUR BABY

Bowel sounds

Sounds are present within

minutes after birth.


10/16

10Rev 8/11

Umbilical cord

y Appearance at birthy How many vessels?y When is a clamp used?y What care should be given to

stump & when?

y When should cord fall off?

Whitish, gray appearance

3 vessels 2 arteries/1 vein

A clamp is placed closer to the

newborn upon delivery so cord

can be cut.

Cord clamp is removed once

stump starts drying and no

longer bleeding. Use sterile

water initially then plain water

to clean cord. Then use triple

due once and continuous

cleansing with water until cord

falls off in 10-14 days.

GENITOURINARY TEXTBOOK YOUR BABY

Voiding

y Pattern (times/day)y Time of first void

Babies void 2-6 times/day for 1-

2 days; 6-10 x day by 5th

or 6th

day.

Within first 24 hours.

What is the significance/cause of

rust-stained urine or brick

dust?

Normal uric acid crystal findings

Pseudomenstruation

y Definition & causey Normal or abnormal?

Blood tinged discharge caused

by pregnancy hormones which is

normal in female newborns.

Where is the normal placementof the urinary meatus for male

infants?

Should be at a tip of penile shaft


11/16

11Rev 8/11

Circumcision

y Definition & methodsy When is it done, by whom,

and where?

y Pre- & post-procedure care

Involves removal of the prepuce

(foreskin) of the glans

Usually performed at hospital

before discharge but never

immediately after birth. If

Jewish then 8th

day after birth.

Feeding with held 2 hours

before to avoid vomiting.

Positioned on a plastic

restraining board, penis cleaned

with soap and water. A yellow

clamp is applied, prepuce

excised and a plastic bell fitted.

Baby is monitored for bleeding q

30 minutes 1st hour and q hour

for 4-6 hours.TRUNK AND EXTREMITIES TEXTBOOK YOUR BABY

ROM, symmetry, & muscle tone

Check, inspect, palpate for full

ROM of all body parts. Note

symmetry of motion and muscle

tone.

Simian line/crease (definition &

most common chromosomal

abnormality seen with)

The crease on the palms appear

to fuse. Downs, Rubella,

Turners, Klinefelter.

SyndactylyWebbing of fingers or fusion of

one or more fingers or toes.

PolydactylyHaving more than the normal #

of fingers or toes.

Erbs Palsy (Erb-Duchenne

Paralysis)

Paralysis of the muscles of

the upper arm due to injury

of the a5th and 6th

cervical

roots of the brachial plexus.

Hand muscles are not

affected.


12/16

12Rev 8/11

Developmental dysplasia of the

hip (DDH)

y What maneuver is used tocheck for DDH?

y What assessment findingsmay be seen with DDH?

Head of femur on legs are flexed

and abducted, placement in

acetabulus If normal femur is

intact.

Asymmetry of gluteal and thigh

folds with shortening of thigh

upon rotation you hear a click

Limited hip abduction with

flexion

Apparent shortening of femur is

indicated by level of knee

flexion.

Ortolani test with femoral head

moving in/out of acetabulus.

ANUS/STOOLS TEXTBOOK YOUR BABY

Placement of anus

y Where should the analopening be?

y What is an imperforateanus?

The outlet of the rectum lays in

the fold between the buttock

Imperforate anus is closed (no

opening)

Stool

y Pattern (times/day)y Time of first stooly Define meconium,

transitional, & milk stools.

Include when each should be

passed.

Pattern and times vary

Passage of 1st 24 48 hours

although it may be delayed upto 7 days in LBW babies.

Meconium babies 1st stool

filled with bacteria is greenish

black, viscous and contains

blood.

Transitional 3rd

day it is

greenish brown to yellowish

brown, thin and less sticky. Can

contain milk curds.

Milk stool 4th day breastfed

stool is yellow, pasty and sour

smelling. Formula fed pale

yellow firmer and stinky.

NEWBORN REFLEXES TEXTBOOK YOUR BABY


13/16

13Rev 8/11

Rooting reflex Touch babys cheek and baby

turns head toward stimulus and

opens mouth.

Suck/Swallow reflex Touch infant cheek, baby opens

mouth, takes hold and sucks and

swallow which is usuallycoordinated.

Palmar & plantar grasp reflexes

y Definition & how to elicit.y When should they

disappear?

Palmar place finger in palm of

infants hand and its fingers will

wrap around your finger.

Palmar lessens by 3-4 months.

Plantar place finger at base of

toes and babys toe will curl

downward. Plantar lessens by 8

months.

Tonic neck or fencing reflex

With infant falling asleep or

sleeping turn head quickly to

left side and opposite arm

extends and leg flexes. (Same

on opposite rt side.)

Moro/Startle reflex

y Definition & how to elicit.y When should it disappear?

Hold infants head in semi sitting

and allow head and trunk to fall

backwards - 6 months it should

disappear

Place infant on flat surface and

strike surface and/or sharp hard

clap 6 months it disappearsunless there is a neurological

problem.

Dance or step reflex

Hold baby vertically, placing the

foot on flat surface and it will

stimulate movement like

walking.

Babinski reflex

y Definition & how to elicit.y When should it disappear?

+ sign - Dorsiflexion of great toe

when sole is stimulated by

upward stroking of foot sole.

Absence requires neurologicevaluation. Disappears after 1

year.


14/16


15/16

15Rev 8/11

When is the transition period? What occurs during

the transition period?

Period from birth to 4-6 hours later in which the

infant passes through a period of reactivity sleep

and a 2nd period of reactivity.

Transition period Period between intrauterine

and extrauterine existence.

1st phase lasts up to 30 minutes after birth (1st

period of reactivity) HR increases rapidly to 160-

180 bpm but gradually falls after 30 minutes to a

baseline rate of 100-120 b[m. RR is irregular and

between 60-80 breaths/min. Fine crackles,

audible grunting, nasal flaring and retractions of

the chest but will cease within 1st

day of birth. The

infant is alert, has spontaneous startles, tremors,

crying and movement of the head from side to

side. Bowel sounds audible and meconium may be

passed.

Sleep or decrease in motor activity Period of

unresponsiveness lasts 6-200 minutes.

2nd phase reactivity occurs again between 4 and

8 hours and lasts 10 minutes to several hours.

Brief periods of tachycardia and tachypnea,

increase muscle tone, skin color and mucous

production. Most babies pass the meconium

during this phase.

What is unique to the newborn in relation tothermoregulation? What temp is hypothermic?

What temp is considered a fever?

Control of temperature: a balance between heatloss and heat production. Newborns attempt to

stabilize their core body temperature within a

narrow range. Hypothermia - < 36.5 C

Hyperthermia- > 37.0 C

What is cold stress? Briefly explain how it can be

prevented.

Excessive heat loss that results in increased RR and

non-shivering thermogenesis to maintain body

core temperature. Mother/baby skin to skin

contact.

Explain the reasoning for vitamin K injection and

Erythromycin eye ointment administration for

newborns.W

here& when is the IM injectiongiven?

K injection helps prevent clotting problems

Measure to prevent gonorrhea and Chlamydia eyeinfections

K is given IM soon after birth to prevent

hemorrhage

NUTRITION QUESTIONS YOURANSWERS


16/16

16Rev 8/11

What is the average stomach capacity in mL of a

full-term newborn?

5-7 ml (size of fist)

When should PO feedings be started in the healthy

full-term newborn?

As soon as possible after birth for full term PO

feedings

How often should a full-term healthy newborn bebreastfed? What if formula-fed?

Breast fed 8-12 x qd every 2-3 hoursFormula fed 8-12 x qd every 2-3 hours

What is the average amount consumed in

mL/feeding for a full-term healthy newborn?

90-150 ml by end of 2nd week at every feeding.

What is the average time it takes for the healthy

newborn to breastfeed effectively? bottle-feed?

Breast fed avg. time 5 to 10 minutes per breast

Bottle fed avg. time 20-40 minutes

How many kcal/kg/day does a healthy full-term

newborn need?

120 Kcal/kg/day

W

hat is the average amount of kcal/oz inbreastmilk and standard formula? Breast milk 20 kcal/ozFormula 24 Kcal/oz

Using your babys current weight, calculate how

many kcal/d he/she needs.

Based on your babys formula or breastmilk,

calculate how many ounces per feeding your baby

needs.

EXPERIENCEEVALUATION YOUR COMMENTS

Describe any significant findings or needs of the

infant you cared for in the nursery.

What did you learn from your nursery experience?

Documents

Newborn Assessment 2.16