PEDIATRIC ASSESSMENT

Immediately after delivery, the general state of the newborn should be evaluated
while the infant is supine under a radiant warmer with the temperature probe
attached to the abdomen. APGAR scores are assigned at 1 and 5 minutes after
delivery.

APGAR SCORE ASSESMENT

PROCEDURE NORMAL FINDINGS DEVIATIONS FROM

NORMAL
Auscultate apical pulse >100 bpm <100 bpm indicates
bradycardia; absent heart
beat indicates fetal
distress.
Inspect chest and Crying Absent, slow, irregular
abdomen for respiratory respirations.
effort.
Stroke back or soles of Crying Delayed neurologic
feet. function may be seen in
grimace, no response.
Inspect muscle tone by Extremities flexed, active Moderate degree of
extending legs and arms. movement flexion, limp may indicate
Observe degree of flexion neurologic deficits.
and resistance in
extremities.
Inspect muscle tone by Full body pink. Cyanosis, pale
extending legs and arms. Acrocyanosis
Observe degree of flexion
and resistance in
extremities.
Determine total apgar 8-10 points <8 points indicate poor
score at 1 and 5 minutes transition from
after birth intrauterine into
extrauterine life.

APGAR SCORING

0 1 2
Heart rate Absent <100 bpm >100 bpm
Respiratory rate Absent Slow, irregular Good lusty cry
Reflex irritability No response Grimace, some Cry, cough
motion
Muscle tone Flaccid, limp Flexion of Active flexion
 extremities
Color Cyanotic, pale Pink body, Pink body, pink
Acrocyanosis extremities

After the Apgar score has been assigned, a thorough assessment including vital
signs, measurements, and gestational age assessment is performed.

PROCEDURE NORMAL FINDINGS DEVIATIONS FROM

NORMAL FINDINGS
Monitor axillary 36.4—37.2 <36.4°: hypothermia,
temperature. which may indicate sepsis
>37.2: hyperthermia,
which may indicate
infection or improper
monitoring of temperature
probe
Inspect and Auscultate Easy, nonlabored, clear Labored breathing, nasal
lung sounds. lungs bilaterally flaring, ronchi, rales,
retractions, grunting
Monitor respiratory rate. Rate: 30-60 breaths/min Rate <30 or >60
breaths/min is seen with
respiratory distress
Auscultate apical pulse. Regular 120-160 bpm (100 Irregular <100 or >180
sleeping, 180 crying) bpm may indicate cardiac
abnormalities
Weigh newborn unclothed 2,500-4,000 g <2,500 g
using a newborn scale. >4,000 G
Measure length 44-5 cm <44 cm
>55 cm
Measure head 33-35 cm <33 cm
circumference >35 cm
Measure chest 30-33 cm <29 cm
circumference >34 cm

ASSESSMENT OF GESTATIONAL AGE

The newborn’s gestational age is examined within 4 hours after birth to identify any
potential age-related problems that may occur within the next few hours. The
newborn’s neuromuscular and physical maturity is examined. After examination,
boxes on New Ballard Scale that most closely describe and depict the newborn’s
neuromuscular and physical maturity are marked, and scores are assigned to assess
gestational age.

PROCEDURE NORMAL FINDINGS DEVIATIONS FROM

NORMAL
Assess neuromuscular
maturity • Arms and legs • Arms and legs limp,
• Posture 9with flexed extended away
newborn from body seen
undisturbed) with premature
infants
• Premature infants
• 0-30°
may have square
• Square window:
window
bend wrist toward
measurement of
ventral forearm
>30°
until resistance is
• Elbow angle <90°,
met
rapid recoil to
• Arm recoil: • Elbow angle >110°,
flexed state
bilaterally flex delayed recoil seen
elbows up with in premature infants
hands next to
shoulders and hold
approximately 5
seconds; extend
arms down next to
side, release; • <100°
• >100°
observe elbow
angle and recoil
• Popliteal angle: flex
thigh on top of
abdomen; push
behind ankle and
extend lower leg
toward head until
resistance is met; • Elbow position less
• Elbow position
measure angle than midline of
midline of chest or
behind knee. chest
greater, toward
• Scarf sign: lift arm opposite shoulder
across chest toward seen in premature
opposite shoulder infants.
until resistance is
met; note location • Popliteal angle
of elbow in relation • Popliteal angle
<90°, heel distal
to middle of chest >90°, heel proximal
from ear
• Heel to ear: pull leg to ear seen in
toward ear on same premature infants
side, keeping
 buttocks flat on
bed, inspect
popliteal angle and
proximity of heel to • Few or no vessels in • Translucent, visible
ear. the abdomen, veins, rash,
cracking in ankle leathery, wrinkled
area especially skin seen in
Assess physical maturity
postmature infants
• Observe skin
• Abundant amount
• Thinning, balding on
of fine hair on face
back, shoulders,
seen in premature
knees
infants
• Inspect for lanugo • Anterior transverse
• Creases on anterior crease on sole only,
two thirds or entire no creases, fewer
• Inspect plantar sole creases indicate
surface of feet for prematurity
creases • Absence of bud
tissue, bud <3 mm
• Raised areola, full
seen in premature
areola infants
• Inspect and palpate
breast bud tissue
with middle finger
and forefinger; • Pinna slightly
measure bud in curved, slow recoil
• Pinna well curved,
millimeters seen in premature
cartilage formed,
• Observe ear infants
instant recoil
cartilage in upper
pinna for curving.
Fold pinna down
• Male: Decreased
toward side of head • Male; deep rugae;
presence of rugae;
and release, testes positioned testes positioned in
observe recoil of down in scrotal sac upper inguinal canal
ear. Female: Labia Female: labia
• Inspect genitals. majora cover majora and labia
Male: observe minora and clitoris minora equally
scrotum for rugae
prominent seen
an palpate position
with premature
of testes
infants
Female: observe
labia majora, labia
minora and clitoris • Total score: 35-45 • Total score: <35
 points points or >45 points
• Gestational age:
<38 or >42 weeks
Determine score rating • Gestational age: 38-
• Add the total scores 42 weeks
from both tables
• Plot total score in
column on right-
hand side of page;
this score
corresponds to the • Les s than 10th
number in weeks on percentile (small for
• 10th through 90th
the maturity rating gestational age),
percentile is
scale, circle the greater than 90th
appropriate for
number of weeks. percentile (large for
gestational age
• Using gestational gestational age)
weeks assessed,
plot weight, length
and head
circumference