Newborn assessment

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

Vital Signs

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

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

Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)

Length range - 48 to 53 cms (19 - 21 inches)

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
Vernix caseosa
Lanugo
Turgor good with quick recoil
Hair silky and soft with individual strands
Nipples present and in expected locations
Cord with one vein and two arteries
Cord clamp tight and cord drying
Nails to end of fingers and often extend slightly beyond

Common variations

Acrocyanosis - result of sluggish peripheral circulation

Mongolian spots in infants of African-American descent

Mottling

Physiologic jaundice
 Milia

Erythema toxicum

Petechiae/ bruises over presenting part

Skin tags usually around ears or digits (tied off)
Harlequin color change

Signs of potential distress or deviations from normal findings

Jaundice within 24 hours of birth

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
Forceps marks
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

Molding of fontanels and suture spaces

Signs of potential distress or deviations from normal findings

 Fontanels that are bulging or depressed
Hydrocephalus
Macrocephaly
Cephalhematoma

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
 Uncoordinated movements

May focus for a few seconds

Signs of potential distress or deviations from expected findings

Discharges
Chemical conjunctivitis

Opaque lenses
Absence of Red Reflex
Epicanthal folds in newborns not of Oriental descent
"Doll's eyes" beyond 10 days of age
Reflexes absent
Subconjunctival hemorrhage
Ears

Expected findings

Pinna top on horizontal line with outer canthus of eye

Loud noise elicits Startle Reflex

Flexible pinna with cartilage present

Common variations

Skin tags on or around ears

Signs of potential distress or deviations from expected findings

Ear placement low

Preauricular sinus

Clefts present
Malformations
Cartilage absent

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

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

Palate high arched

 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

Common variations

Epstein's pearls on ridges of gums

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
Candida Albicans

Diminished tongue movement

Precocious teeth

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
 Large fat pad on back of neck
Palpable crepitus, movement with palpation of clavicle

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

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
Legs appear bowed
Feet appear flat

Palmar creases present

Sole creases present

Negative hip click

Grasp reflex present
Signs of potential distress or deviations from expected findings

Unequal tone
Asymmetrical movement of extremities
Polydactyly

Syndactyly
Unequal leg length
Asymmetrical skin creases posterior thigh

Dislocation of hip
 Simean crease
Persistent cyanosis of nail beds
Marked metatarus varus

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