GENERIC NEWBORN ASSESSMENT PREP

Directions: Prior to clinical, complete this form and fill in all biological and psychosocial assessment areas.

#1 define each area of assessment, #2 fill in rationale for assessments, #3 fill in expected assessment data for normal term

newborn .

ASSESSMENT AREA RATIONALE FOR ASSESSMENT EXPECTED FINDINGS FOR

NORMAL TERM NEONATE

A. General Appearance

1. Gestational Age by

Maturity Rating

2. Weight

3. Activity

4. Posture

5. Symmetry

6. Temperature

1.

2. Weights above 90th percentile common

in neonates of diabetic mothers. Below

10th percentile due to prematurity,

intrauterine growth restriction, or

malnutrition.

3. Hypoglycemia, drug withdrawal, cold

stress can cause tremors. Hypotonia ,

hypertonia, paralysis, related to spinal

1. 37-42 weeks for singleton.

2. 2500-4000g (5 lbs. 8oz. -8 lbs.

13oz.)

3. Positive newborn reflexes.

4. Flexed position.

5. Symmetrical.

6. 36.4-37.2C (97.5-99F)

injuries, nerve damage, hypoxia.

4. Extension of extremities can be related

to prematurity, effects of medication given

to mother during labor (magnesium sulfate,

analgesics, anesthesia) birth injuries,

hypothermia, hypoglycemia.

5. Non symmetrical.

6. Hyper/Hypo thermia, related to

environment (too many blankets, not

enough), infection, neurological damage.

B. Skin

1. Color

2. Coatings (i.e. – Lanugo,

vernix)

3. Hydration

1. Jaundice in 1st 24 hours. Pallor (anemia,

hypothermia, shock or sepsis).

2.Abundant Lanugo indicative of

prematurity. Greenish/yellow vernix

indicative of meconium passage during

1. Pink with acrocyanosis.

2. Lanugo on back, shoulders, and

forehead, decreases with advancing

gestation. Might have small amounts of

vernix in auxiliary and genital areas.

4. Rashes

5. Bruises

6. Pigmentation

pregnancy or labor.

3. Assess turgor.

4. Assess for abnormal rash.

5. Persistent ecchymosis or petechiae

indicative of thrombocytopenia, sepsis, or

congenital infection.

6. Mottling due to cold environment.

7. Pilonidal dimple, small pit or sinus in

the sacral area at top of crease between

buttocks, sinus can become infected later in

life.

3. Skin elastic without tenting.

4. Milia on bridge of nose and chin,

erythema toxicum. red, white, yellow

papules).

5. None, or explained by actual cause.

6. Mongolian spots (flat bluish

discoloration on lower back and or

buttock), hemangiomas (stork bites),

Nervus flammeus (purple to red flat

areas, permanent), Strawberry

hemangiomas (raised, bright red

lesions, resolve during early

childhood).

C. Head 1. Microcephaly, below 10th percentile. 1. 33-35.5cm (13-14 inches).

2,3. Molding present, fontanels open,

1. Circumference

2. Shape

3. Fontanels

4. Eyes

5. Ears

6. Neck

Macrocephaly, above 90th percentile.

2. Caput succedaneum, from prolonged

pressure against cervix. Cephalhematoma,

hematoma between periosteum and skull

with unilateral swelling, well defined,

related to trauma, can lead to jaundice.

3. Firm and bulging (not while crying) can

be increased ICP. Depressed can mean

dehydration. Bruising and lacerations from

fetal scalp electrode or vacuum extractor.

4. Cataracts indicated by absent red light

reflex. Neuro trauma can cause unequal

pupil reactions. Osteogenesis imperfecta

indicated by blue sclera.

5. Low set ears indicative of genetic

disorders (down's syndrome). Absent

startle reflex due to possible hearing loss.

soft, intact and slightly depressed.

Anteriro fontanel diamond shaped 2.5-

4cm. Posterior fontanel triangular 0.5-

1cm. May be difficult to palpate with

excessive molding. Increased molding

causes overriding sutures.

4. Equal and symmetrical in size and

placement. Can follow objects within

12 inches of visual field. Tear

production not active until 2 months.

Iris's blue, grey or brown. Sclera white

or bluish white. Positive red light

reflex and blink reflex.

5. Pinna well formed without

deformities, top is aligned with

external cantus of eye. Responds to

noises with positive startle signs.

6. Webbing indicates genetic disorders.

Absent tonic neck reflex indicates nerve

injury.

Respond more to high pitched vocal

sounds.

6. Neck is short with skin folds.

Positive tonic neck reflex.

D. Chest

1. Circumference

2. Shape

3. Breast

4. Heart (rate, rhythm, sound)

5. Respiratory (rate, effort)

6. Clavicles

1. Funnel chest is congenital abnormality.

2. Pigeon chest can obstruct respirations.

3. Chest retractions are sign of respiratory

distress.

4. Tachycardia >160 bpm, indicates

possible sepsis, respiratory distress or

congenital heart abnormality. Bradycardia

<100 bpm, indicates possible sepsis,

increased intracranial pressure, or

hypoxemia.

1. 30.5-33cm (12-13 inches). or 2-3 cm

less than head circumference.

2. Barrel shaped and symmetrical.

3. Engorged due to maternal hormones,

resolves within a few weeks. Can have

clear or milky fluid from nipples.

4. 120-160 beats per minute. (100

while asleep), (180 while crying). Most

murmurs not pathological and resolve

by 6 months.

5. Apnea >15 seconds. Tachypnea that may

be related to sepsis, hypothermia,

hypoglycemia, or respiratory distress

syndrome. Respirations <30 may be related

to maternal analgesia and or anesthesia

during labor.

6. Swelling, crepitus and or neck

tenderness can indicate broken clavicle.

30% of murmurs resolve within 2 days

of birth.

5. 30-60 breaths per minute slightly

irregular, diaphragmatic, and

abdominal breathing. Clear and equal,

may have crackles during first few

hours of birth, due to retained amniotic

fluid.

6. Absent swelling, crepitus or

tenderness.

E. Abdomen

1. Cord

2. Shape

3. Stools

1. One artery or vein often associated with

heart or kidney malformation.

2. Asymmetrical shape can indicate

abdominal mass.

3. Failure to pass meconium stool often

associated with imperforated anus or

1. Cord is opaque or whitish blue, with

two arteries and one vein, covered in

Wharton's jelly. Becomes dry and

darker in color within 24 hours post

birth, falls off within 2 weeks.

2. Soft, round, protuberant, and

meconium ileus. symmetrical.

3. Passage of meconium stool within

48 hours post-birth.

F. Genitals GI, Females:

Prominent clitoris and small labia minora

often present in preterm neonates.

GI, Males:

Hypospadias, urethral opening is on ventral

surface of penis.

Epispadias, urethral opening is on dorsal

side of penis.

Undescended testes, testes not palpated in

the scrotum.

Hydrocele, enlarged scrotum due to excess

fluid.

Inguinal hernia.

Male/Female: No urination in 24 hours

GI, Females:

Labia majora covers labia minora and

clitoris.

Labia majora and minora may be

edematous.

Pseudo menstruation due to abrupt

decrease of maternal hormones.

Whitish vaginal discharge in response

to maternal hormones.

Urination within 24 hours.

Urinary meatus midline and an

uninterrupted stream is noted on

voiding.

GI, Males:

may indicate urinary tract obstruction,

polycystic disease, or renal failure.

Ambiguous genitalia may require genetic

testing to determine sex.

Urinary meatus at tip of penis.

Scrotum is large, pendulous and

edematous with rugae present.

Both testes palpated in scrotum.

Urinates within 24 hours with an

uninterrupted stream.

G. Skeletomuscular

1. Extremities

2. Spinal Column

1. Polydactyly, extra digits may indicate a

genetic disorder.

Syndactyly, webbed digits may indicate a

genetic disorder.

Unequal gluteal folds and/or positive

Barlow-Ortolani maneuver are associated

with congenital hip dislocation.

Decreased ROM, muscle tone, may

indicate birth injury, neurological disorder,

or prematurity.

Simian creases, short fingers, wide space

1. Arms and legs are symmetrical in

length and equal in strength.

10 fingers and 10 toes present.

Full ROM of all extremities.

No clicks at joints.

Equal gluteal folds.

2. C curve spine with no dimpling.

between big toe and second toe are

common with Down's syndrome.

2. Any openings.

H. Reflexes

1. Suck & Rooting

2. Grasp

3. Moro

4. Babinski

5. Cry

1. May not respond if recently fed.

Prematurity or neurological defects may

cause weak or absent response.

2. Palmer, absent or weak response

indicates a possible CNS defect, nerve or

muscle injury.

Plantar, weak or absent may indicate

possible spinal cord injury.

3. Preterm or sleepy infants may have slow

response.

Asymmetrical response may be related to

temporary or permanent birth injury to

clavicle, humerus, or brachial plexus.

4. Absent or weak may indicate

1. Turns head towards direction of

stimulus and opens mouth. Sucking

motion occurs.

2. Palmar, neonate grasps fingers

tightly.

Plantar, toes flex tightly down in a

grasping motion.

3. symmetrical abduction and

extension or arms and legs and legs

flex up against trunk.

Neonates make a C shape with thumb

and index finger.

4. Hyperextension and fanning of toes.

neurological defect.

5. Prolonged crying can be a late sign of

hunger, colic, or due to discomfort or

illness.

5. Crying is the normal communication

of a neonate expressing needs, ie: to

feed, be changed, or held.

I. Behavior Initial period of reactivity, 15-30

minutes, alert and active, rr irregular

and rapid up to 90 breaths per minute.

HR rapid as high as 180 beats per

minute. Brief periods of apnea may

occur.

Period of relative inactivity, 30

minutes - 2 hours, sleep state,

unresponsive to external stimuli.

Decreased respiratory rate, can be

slightly below normal range. Heart rate

decreases but stays within normal

range.

Second period of reactivity follows

period of inactivity, lasting 2-8 hours.

Varies between active alert and quiet

alert state. Periods of rapid respirations

responding to stimuli and activity.

Heart rate varies based on activity and

stimulation. Responds to external

stimuli.