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______ 1
Rev 8/11

NEWBORN ASSESSMENT
**Complete textbook description BEFORE coming 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 Birth weight (lbs, oz, kg, or g) Safe amount of weight loss (ounces AND grams) Length (cm or in)

TEXTBOOK DESCRIPTION 2500 4000 g (3400-female/3500-male) 10 % loss (34-35 g) (0.035 ounces in a gram and 1.19-1.23 ounces) 45-55 cm Measure top of head to heel 32-36.8 cm Measure a greatest diameter occipito-frontal circumference < or = 30 cm (average 30-33 cm Measure @ nipple line TEXTBOOK Axillary 37 degrees C (36.5 37.2) 8-10 hours old 1 full minute 100-160 beats/min Listen 4th intercostal space 1 full minute 30-60 breaths/min

YOUR BABY

**Do the math!!**

Head circumference (cm or in)

Chest circumference (cm or in) VITAL SIGNS Temperature y What is the preferred method of measurement? y What is a normal newborn temperature? y When should it stabilize? Apical pulse y How long should HR be counted in newborn? y What is the normal HR in a newborn? Respiratory Rate y How long should RR be counted in a newborn? y What is the normal RR in a newborn?

YOUR BABY (MOST RECENT)

2
Rev 8/11

NIPS Neonatal Infant Pain Scale PIPP Premature Infant Pain Profile CRIES Crying, Req increased 02, increased V/S, expression and Neonatal Pain sleeplessness y List 2 pain scales used for 1)containment swaddling assessment of neonatal pain. 2)Non-nutritive sucking pacifier y List 3 nonpharmacological 3)Skin to skin contac methods of pain 4)Distraction-Visual, oral, management. auditory y List 3 pharmacological agents 1)Non-opiod Tylenol (mild used for neonatal pain. moderate 2)Opiod MS04 & Fentanyl & Toradol 3)Epidural Nerve Block 4)Sweeteze COMMON LABS Bilirubin (serum, TcB) y What is the normal level? y When will the level peak? Glucose (one touch, accucheck) y When is it checked? y What level is hypoglycemic? y What interventions are initiated for low levels? Newborn screen y When is it done? y List 3 disorders that can be detected. SKIN Color & temperature T 36.5 37.0 C Hands and feet appear slightly cyanotic. Intermittently over 710 Condition that is marked by discolored areas. Looks like lace. TEXTBOOK 5-6 mg/dl to 12 mg/dl 60-70 hours from birth Within 2-3 hours of birth < 36 mg/dl 1)Feeding immediately 2)IV Dextrose Within 1-2 hours of birth PKU, T4, Sickle Cell, Galactosemia, Drug Serum TEXTBOOK Pink or acrocyanotic

**Use NIPS scale to rate your baby s pain with assessment.**

YOUR BABY

YOUR BABY

Acrocyanosis

Mottling

3
Rev 8/11

Harlequin sign

Erythema toxicum

Milia

Miliaria (see Taber s)

Jaundice y Definition, causes, treatments, & complications. y Briefly differentiate between physiologic & pathologic. y List 2 possible causes of pathologic jaundice. y What is breastfeeding jaundice?

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. Innocuous pink popular neonatal rash of unknown origin with super imposed vesicles appearing within 24-48 hours spontaneously goes away. Small white sebaceous glands appearing as tiny white pinpoint papules on the forehead, nose, cheek and chin 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. 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 of RBCs by the immature liver at birth. Pathologic Hemolytic disease: hemolytic anemia, sickle cell, auto immune and mono Breastfeeding Physiologic and results 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. 4

Rev 8/11

Mongolian Spots

Stork bite marks (Telangiectasia nevi)

Port wine stain (Nevus flammeus)

Nevus vasculosus (Strawberry mark)

Vernix caseosa

Lanugo

HEAD AND NECK Size & position

Bluish, gray or dark nonelevated pigmentation areas usually found over the lower back and buttocks and primarily in non-white races A vascular lesion formed by dilatation of a group of small blood vessels. It may appear as a birthmark. 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. Superficial blood vessels are enlarged. Usually congenital and slightly elevated, red, purple on face, neck, head and arms. Protective gray white fatty substance of cheesy consistency covering of the fetal skin. 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. TEXTBOOK Head- 32to 36.8 cm. Measured just above the eye brows

YOUR BABY

5
Rev 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 not enough fluid dehydrated or malnutritioned. 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. The line union in an immovable **Use these terms to document: articulation, as those between palpable, separated, the skull bones. The skull bones overlapping, widely spaced, overlap at the suture lines which &/or closed.** permits adaptation to the various diameters of the mother s pelvis. Baby s head assumes normal shape within 3 days of birth. Shaping of the fetal head to adapt itself to the dimensions of the birth canal during descent through the pelvis. Forcep injury produces linear marks across both sides of the face in the shape of the blades of the forceps. Forceps help extract head from birth canal.

Posterior fontanel y Measurement & location. y When should it close? Suture lines y Definition & function.

Molding

Forcep marks

6
Rev 8/11

Cephalhematoma y Definition & location. y Most common causes y Cross or does not cross suture lines? y Complications or special monitoring needed if noted

Caput Succedaneum y Definition & location. y Cause y Cross or does not cross suture lines?

EYES Placement

Epicanthal folds

Vision y PERRLA? y What is the visual acuity of a full-term newborn? y What are the newborn s visual preferences (color, black & white, distance, patterns)?

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). Diffuse edema of the fetal scalp that crosses the suture lines. Head compression against the cervix impedes venous return forcing serum into interstitial tissue. 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. TEXTBOOK Eyes and space between eyes each 1/3 the distance from outer to outer canthus. E.F. are characteristic in some races. However, EF can present with Down s syndrome. 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 prefer black and white patterns. TEXTBOOK

YOUR BABY

NOSE

YOUR BABY

7
Rev 8/11

Observe shape, placement, patency and configuration midline, nose breather, flat or deviated. Sneezing & nasal mucus normal Sneezing is normal and is used or abnormal? to clear nasal mucous with some or no drainage. Choanal Atresia Cyanosis at rest and return of pink color with crying due to y Definition copious drainage and blockage y How is it diagnosed? of bone. EARS TEXTBOOK Placement Line drawn through inner and outer canthus of eyes which reaches to the top notch of ears. Hearing Screen when is it Screened by hospital discharge done? to home after birth. Placement MOUTH Cleft lip or palate y Brief definition. y Discuss how a newborn is assessed for both. TEXTBOOK Midline fissure or opening in the lips or palate resulting from failure of the primary palate to fuse. Perform visual assessment. Facial nerve injury (facial paralysis caused by pressure on facial nerve; often by forceps. Absence of movement in affected sided. Noticeable when baby cries. Small whitish areas found on gum margins and juncture of the hard and soft palate. 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. Sometimes infant cannot breast feed. TEXTBOOK

YOUR BABY

YOUR BABY

Facial nerve paralysis y Define and list S/S. y Most common cause

Epstein's pearls

Thrush (Moniliasis) y Cause & treatment y What if breastfeeding?

CHEST

YOUR BABY

8
Rev 8/11

Nipples y Define breast engorgement of newborns. y Define Witch s milk. Respiratory pattern y Symmetric? y Define periodic breathing & apnea. Are these findings normal or abnormal? y What are S/S of respiratory distress?

Engorgement is the swelling of the breast tissue in both sexes by the hyper-estrogen of pregnancy. Witch s milk is the thin discharge from the nipples. Breaths are shallow and irregular from 30-60 breaths/min. Periodic breathing includes pauses in respirations lasting < 20 seconds, occurs during sleep cycle and decreases with age. Periodic breathing is a normal finding. Respiratory distress - causes nasal flaring, grunting with respirations, intercostals/subcostal retractions. (RR < 30 > 60) 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 a vaginal birth. Heart murmurs Normal during 1st few days of life Murmurs require f/u if there is a murmur + poor feeding, apnea, cyanosis or pallor. TEXTBOOK Sounds are present within minutes after birth.

Breath sounds y What is normally heard? y What may be heard at birth, especially with C-section delivery, and why?

Heart murmurs y Normal or abnormal? y Do murmurs require followup? ABDOMEN Bowel sounds

YOUR BABY

9
Rev 8/11

Whitish, gray appearance 3 vessels 2 arteries/1 vein Umbilical cord y Appearance at birth y How many vessels? y When is a clamp used? y What care should be given to stump & when? y When should cord fall off? 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. TEXTBOOK Babies void 2-6 times/day for 12 days; 6-10 x day by 5th or 6th day. Within first 24 hours. Normal uric acid crystal findings

GENITOURINARY Voiding y Pattern (times/day) y Time of first void What is the significance/cause of rust-stained urine or brick dust ? Pseudomenstruation y Definition & cause y Normal or abnormal? Where is the normal placement of the urinary meatus for male infants?

YOUR BABY

Blood tinged discharge caused by pregnancy hormones which is normal in female newborns. Should be at a tip of penile shaft

10
Rev 8/11

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. TEXTBOOK Check, inspect, palpate for full ROM of all body parts. Note symmetry of motion and muscle tone. The crease on the palms appear to fuse. Down s, Rubella, Turner s, Klinefelter. Webbing of fingers or fusion of one or more fingers or toes. Having more than the normal # of fingers or toes.

Circumcision y Definition & methods y When is it done, by whom, and where? y Pre- & post-procedure care

TRUNK AND EXTREMITIES ROM, symmetry, & muscle tone Simian line/crease (definition & most common chromosomal abnormality seen with) Syndactyly Polydactyly

YOUR BABY

Erb s 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.

11
Rev 8/11

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 Placement of anus y Where should the anal opening be? y What is an imperforate anus? TEXTBOOK The outlet of the rectum lays in the fold between the buttock Imperforate anus is closed (no opening) Pattern and times vary Passage of 1st 24 48 hours although it may be delayed up to 7 days in LBW babies. Stool y Pattern (times/day) y Time of first stool y Define meconium, transitional, & milk stools. Include when each should be passed. 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. TEXTBOOK YOUR BABY

Developmental dysplasia of the hip (DDH) y What maneuver is used to check for DDH? y What assessment findings may be seen with DDH?

NEWBORN REFLEXES
Rev 8/11

YOUR BABY 12

Rooting reflex

Suck/Swallow reflex

Palmar & plantar grasp reflexes y Definition & how to elicit. y When should they disappear?

Touch baby s cheek and baby turns head toward stimulus and opens mouth. Touch infant cheek, baby opens mouth, takes hold and sucks and swallow which is usually coordinated. Palmar place finger in palm of infant s hand and its fingers will wrap around your finger. Palmar lessens by 3-4 months. Plantar place finger at base of toes and baby s toe will curl downward. Plantar lessens by 8 months. With infant falling asleep or sleeping turn head quickly to left side and opposite arm extends and leg flexes. (Same on opposite rt side.) Hold infant s 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 disappears unless there is a neurological problem. Hold baby vertically, placing the foot on flat surface and it will stimulate movement like walking. + sign - Dorsiflexion of great toe when sole is stimulated by upward stroking of foot sole. Absence requires neurologic evaluation. Disappears after 1 year.

Tonic neck or fencing reflex

Moro/Startle reflex y Definition & how to elicit. y When should it disappear?

Dance or step reflex

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

13
Rev 8/11

Trunk Incurvation or Galant reflex

OTHER APGAR y Briefly outline the assessments used in calculating an APGAR. y When is an APGAR scored? Define SGA, LGA, and AGA. (Be sure to include percentages used to define each on growth chart.)

Place infant prone on flat surface, run finger down back 45 cm lateral to spine and trunk should flex and pelvis swings toward stimulated side. Disappears by 4th week after birth. TEXTBOOK HR, RR, Muscle Tone, Reflex Intensity and Color. 0-Absent 1-Slow/weak 2- Good Scored immediately after birth. AGA Appropriate for Gestational Age. (10th 90th Percentile) LGA Large for Gestational Age. (> 90th percentile) SGA Small for Gestational Age (< 10th percentile)

YOUR BABY

** Use Ballard to determine gestational age (____), then plot ht/wt/HC on growth chart. Is your baby SGA, AGA, or LGA?**

GENERAL QUESTIONS

YOUR ANSWERS

14
Rev 8/11

When is the transition period? What occurs during Period from birth to 4-6 hours later in which the the transition period? 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 160180 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. Control of temperature: a balance between heat loss and heat production. Newborns attempt to stabilize their core body temperature within a narrow range. Hypothermia - < 36.5 C Hyperthermia- > 37.0 C Excessive heat loss that results in increased RR and non-shivering thermogenesis to maintain body core temperature. Mother/baby skin to skin contact. K injection helps prevent clotting problems Measure to prevent gonorrhea and Chlamydia eye infections K is given IM soon after birth to prevent hemorrhage YOUR ANSWERS 15
Rev 8/11

What is unique to the newborn in relation to thermoregulation? What temp is hypothermic? What temp is considered a fever?

What is cold stress? Briefly explain how it can be prevented.

Explain the reasoning for vitamin K injection and Erythromycin eye ointment administration for newborns. Where& when is the IM injection given?

NUTRITION QUESTIONS

What is the average stomach capacity in mL of a full-term newborn? When should PO feedings be started in the healthy full-term newborn? How often should a full-term healthy newborn be breastfed? What if formula-fed? What is the average amount consumed in mL/feeding for a full-term healthy newborn? What is the average time it takes for the healthy newborn to breastfeed effectively? bottle-feed? How many kcal/kg/day does a healthy full-term newborn need? What is the average amount of kcal/oz in breastmilk and standard formula? Using your baby s current weight, calculate how many kcal/d he/she needs. Based on your baby s formula or breastmilk, calculate how many ounces per feeding your baby needs. EXPERIENCE EVALUATION Describe any significant findings or needs of the infant you cared for in the nursery. What did you learn from your nursery experience?

5-7 ml (size of fist) As soon as possible after birth for full term PO feedings Breast fed 8-12 x qd every 2-3 hours Formula fed 8-12 x qd every 2-3 hours 90-150 ml by end of 2nd week at every feeding. Breast fed avg. time 5 to 10 minutes per breast Bottle fed avg. time 20-40 minutes 120 Kcal/kg/day Breast milk 20 kcal/oz Formula 24 Kcal/oz

YOUR COMMENTS

16
Rev 8/11