new born physical assessment

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Normal Newborn: General Appearance

• 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

Acknowledgement:

Special thanks to Robert, Barbara, and Allison Clifford for their participation in the preparation of the video clips used in this presentation.

References:

Burns, C.E., Barber, N., Brady, M.A., Dunn, A.M., (1996) Pediatric Primary Care: A Handbook for Nurse Practitioners, Philadelphia, W.B. Saunders Company.

Gorrie, Trula Myers, McKinney, Emily Stone, and Murray, Sharon Smith. (1994). Foundations of maternal newborn nursing,Philadelphia; W. B. Saunders Company.

Wong, Donna L. (l995). Whaley & Wong's nursing care of infants and children; contributing editor, David Wilson. 5th edition. St. Louis: Mosby.

Variations and minor departures in infants (1994), Mead Johnson & Company: Evansville, Indiana.

Vital Signs and General Measurements

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 (Crowing respiratory sound)

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

*Molding refers to the process by which the neonates head is shaped during labor as it passes through the birth canal. The head may become elongated due to the overlapping of the cranial bones at the suture line

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
• Turgor good with quick recoil
• Cord with one vein and two arteries

• Cord clamp tight and cord drying

Photo used with permission*

• Hair silky and soft with individual strands
• Nipples present and in expected locations
• Nails to end of fingers and often extend slightly beyond
• Vernix caseosa - The white, cheesy substance covering the newborn's body. Often present only in the skin folds.
• Lanugo - Fine downy body hair usually distributed over shoulders, sacral area, and back of newborns. Usually disappears before birth or shortly after birth.

Common variations:

ACROCYANOSIS
The result of sluggish peripheral circulation.
Photo used with permission* MONGOLIAN SPOTS 
Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent. Not malignant. Resolves in time.
Photo used with permission*

MOTTLING 
Generalized red and white discoloration of skin of chilled infants with fair complexion.

Photo used with permission*

PHYSIOLOGICJAUNDICE
Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn. Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.
Photo used with permission* MILIA 
Tiny white papules (plugged sebaceous glands) located over nose, cheek, and chin.
Photo used with permission* ERYTHEMA TOXICUM
Photo used with permission*

• Petechiae/ bruises over presenting part.
  Petechiae: Pinpoint, flat hemorrhages often visualized on head, face, and chest. Associated with rapid onset of pressure followed by immediate release of pressure during birthing process. 
  Bruises/Ecchymoses: Larger than petechia, hemorrhagic areas associated with rapid delivery or breech birth.
• Skin tags usually around ears or digits (tied off)
• Harlequin coloring - The color of the newborn's body appears to be half red and half pale. This condition is transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system.

Signs of potential distress or deviations from expected findings:

• Jaundice (within 24 hours of birth) - Unconjugated bilirubin circulating in the blood stream that is deposited in the skin. Skin color may range from yellow to orange to greenish hues.
• 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

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
Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses suture line and decreases rapidly in a few days after birth.

Photo used with permission* Molding of fontanels and suture spaces

    
Photo used with permission*                                          Photo used with permission*

Signs of potential distress or deviations from expected findings:

CEPHALHEMATOMA
Subperiosteal extravasation of blood due rupture of vessels. Swelling increases in size on second and third day after delivery. Often associated with delivery by forceps. Swelling does not cross suture line and may take several weeks after birth. Jaundice may occur as blood cells are broken down as the swelling resolves.

Photo used with permission*

• Hydrocephalus
• Macrocephaly
• 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

Photo used with permission*

• May focus for a few seconds

Photo used with permission*

• Uncoordinated movements

Signs of potential distress or deviations from expected findings:

• Discharges
• Opaque lenses
• Absence of Red Reflex
• Epicanthal folds in newborns not of Oriental descent
• Reflexes absent

• "Doll's Eyes" Reflex (beyond 10 days of age):
  When the head is moved slowly to the right or left, the eyes do not follow nor adjust immediately to the position of the head. This reflex should not be elicited once fixation is present. The persistence of the Doll's Eyes Reflex suggests neurologic damage.

• Chemical conjunctivitis

Photo used with permission*

• Subconjunctival hemorrhage

Photo used with permission*

Ears

Expected findings:

• Loud noise elicits Startle Reflex
• Flexible pinna with cartilage present

• Pinna top on horizontal line with outer canthus of eye

Photo used with permission*

Common variations:

• Skin tags on or around ears

Photo used with permission*

Signs of potential distress or deviations from expected findings:

• Ear placement low
• Clefts present
• Malformations
• Cartilage absent

• Preauricular sinus

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:

• 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

• Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.

Photo used with permission*

• Palate high arched

Photo used with permission*

Common variations:

• Epstein's pearls on ridges of gums

Photo used with permission*

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
• Diminished tongue movement

• Candida Albicans

Photo used with permission*

• Percocious teeth

Photo used with permission*

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

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

Photo used with permission*

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 cyst

Extremities

Expected findings:

• Maintains posture of flexion
• Equal and bilateral movement and tone
• Full range of motion all joints
• Ten fingers and ten toes
• Negative hip click
• Grasp reflex present
• Legs appear bowed

• Feet appear flat

Photo used with permission*

• Palmar creases present

Photo used with permission*

• Sole creases present

Photo used with permission*

Signs of potential distress or deviations from expected findings:

• Unequal tone
• Asymmetrical movement of extremities
• Syndactyly
• Unequal leg length
• Asymmetrical skin creases posterior thigh

Photo used with permission*

• Dislocation of hip
• Persistent cyanosis of nail beds
• Polydactyly

Photo used with permission*

• Simean crease

Photo used with permission*

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