Newborn Physical Assessment by Ms. Mevelle L. Asuncion

8/4/2019 Newborn Physical Assessment by Ms. Mevelle L. Asuncion

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Physical Assessment

of the Newborn


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Table of Contents

Normal Newborn: General Appearance Vital Signs and General Measurements Skin

Head, Eyes, Ears Nose, Mouth, Throat, and Neck Chest and Abdomen Female Genitalia and Male Genitalia

Back and Rectum. Extremities Neuromuscular System


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Normal Newborn: General

Appearance


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Vital signs : Weight

Weight : 2.5 kg 3.5 kg

Sigs of potential distress or deviation fromexpected findings

4.7 kg is unusual.. A maternal illness should be

suspected like diabetes.

75 90 %of the newborns weight is fluid.


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Vital Signs: 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 fromexpected findings:

Although murmurs may be due to transitional circulation-allmurmurs should be followed-up and referred for medical evaluation

Deviation from range

Faint sound


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Vital Signs: Respiration

Range: 30 to 60 breaths per minute

Common variations:

Bilateral bronchial breath soundsMoist breath sounds may be present

shortly after birth


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Vital Signs: BP

Blood pressure - not done routinelyFactors 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


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Vital Signs: Temperature

Range: 36.5 to 37.5 rectal

36.5 37.2 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


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Vital Signs

Newborn lose heat by 4 mechanism:a.Convection

b.Conductionc. Radiationd.Evaporation


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Important terms to

remember:

Brown fats

Kangaroo care.


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Normal newborn

General appearance

Well flexed full range of motion , spontaneous

movement.


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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 - 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 birthor shortly after birth.

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


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Skin: Expected findings

Skin reddish in color, smooth and puffy at birth


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Skin: Common Variations

Acrocyanosis - result of sluggish peripheral circulation


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Mongolian spots in infants

of African-American descent

Patch of purple-black or

blue-black colordistributed overcoccygeal and sacralregions of infants ofAfrican-American or

Asian descent.

Not malignant.

Resolves in time.


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Mottling: Generalized red and white discoloration of skin of chilled

infants with fair complexion.


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Physiologic Jaundice:

Hyperbilirubinemia not associated with hemolytic disease or otherpathology in the newborn

Jaundice that appears in full term newborns 24 hours after birth andpeaks at 72 hours

Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.


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Milia: Tiny white papules (plugged sebaceous glands) located

over nose, cheek, and chin.


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Erythema toxicum:


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Petechiae/ bruises over presenting part

Petechiae:

Pinpoint, flat hemorrhages often visualized onhead, face, and chest. Associated with rapidonset of pressure followed by immediaterelease of pressure during birthing process.

Bruises/Ecchymoses: Larger than petechia, hemorrhagic areas

associated with rapid delivery or breech birth.


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Skin tags usually around ears or digits(tied off)

Harlequin color change:

The color of the newborn's body appears tobe half red and half pale. This condition istransitory and usually occurs with lusty crying.

Harlequin Coloring may be associated with toan immature vasomotor reflex system.


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Signs of potential distress or deviations from normalFindings:

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

Forceps marks


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Forceps marks:


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Desquamation : within 24 hours of birth,the skin of the newborn has become dry ,

particularly evident in the palm o the handand sole of the feet.


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Vernex caseosa : a white cream likesubstance that serves as skin lubricant.

The color of the vernix carefully noted because ittakes on the color of the amniotic fluid.


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Lanugo. : is a fine downy hair thatcover the newborn shoulder, back andupper arm

Age of two weeks they are disappear.


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Birth marks

Hemangiomas

Nevus flammeus :

Dark lesions commonly called port wine stain due to itsdeep color.

Do not fade either.


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Straberry hemangiomas :Elevate areas that forms by immature capillaries and

endothelial cells.

Appear in termed neonates appear up to 2 weeks.

Not present in preterm infants. Becauseof immature epidermis.

Up to 10 ears older before its complete absorption.


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Cavernous heangiomas : are dilatedvascular spaces. They are usually raised andresemble a strawberry hemangiomas in appearance.


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Craniotabes : is localized softening of thecranial bones. The bones is so soft that theexamminindg finger can indent it..

The condition correct itself without treatment.


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Normal NewbornGeneral Appearance:

A. Head

symmetry

-minor asymmetry is common and should

equalize by approximately 4 mos.


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General Measurements

Head circumference: 33 to 35 cm

Expected findings Head should be 2 to 3 cm larger than

the chest


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HEAD: Expected findings

Anterior fontanel - diamond shaped 2-3 -3-4 cm

Posterior fontanel - triangular 0.5 - 1 cm

Fontanels should be soft, firm and flat

Sutures should palpable with small

separation between each Forehead is large and prominent


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Head: Common Variations

Caput succedaneum: Swelling of the soft tissue of

the scalp caused bypressure of the fetal head on

a cervix that is not fullydilated.

Swelling crosses suture lineand decreases rapidly in afew days after birth.

Reabsorb within 12 hoursafter birth or few days


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Molding of fontanels and suture spaces


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Signs of potential

distress or deviations

from normal findings:

Fontanels that arebulging or depressed

Hydrocephalus

Macrocephaly

Cephalhematoma

Closed sutures

Cephalhematoma


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Cephalhematoma:

Subperiosteal extravasation of blood due ruptureof vessels.

Swelling increases in size on second and thirdday 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.


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Neck: Expected Findings

Short and thick

Turns easily side to side

Clavicles intact Tonic neck reflex present

Neck-righting reflex present

Some head control


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Neck


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 palpationof clavicle


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Turner syndrome: Abnormal skin foldsover the back of the neck can be a marker of for

genetic abnormality


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Examining the neck

In newborn and infant. Nuchal rigidity is a morereliable indicator of meningeal irritation than is brudzinskisign or kernigs sign


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Normal newborn

-bruised &/or puffy eyelids are normal

-sclerae white to bluish white; slightly brownish frequent innewborns of African descent

-small conjunctival, scleral & retinal

-erythromycin & tetracycline are now frequently usedprophylactically instead of silver nitrate. If silver nitrate drops areused, it may cause edema & chemical conjunctivitis which mayappear a few hrsafter instillation and disappear in 1-2 days

Eyes


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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


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Red reflex : Is extremely important inthe detection of retinoblastoma, a childhood

eye cancer.

Red reflex absent

Red Reflex Absent


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Eyes: Common Variations

Edematous eyelids: Uncoordinated movements:

May focus for a few seconds


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Eyes

Signs of potential distress or deviationsfrom expected findings: Discharges Opaque lenses

Absence of Red Reflex Epicanthal folds in newborns not of Oriental descent "Doll's eyes" Reflex beyond 10 days of age

When the head is moved slowly to the right or left, the eyes donot 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.

Reflexes absent


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Eyes

Chemical conjunctivitis Subconjunctivalhemorrhage


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Ears: Expected findings

Pinna top onhorizontal linewith outercanthus of eye

Loud noiseelicits StartleReflex

Flexible pinnawith cartilagepresent

Trisomy 18 and13 syndrome.


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Ears: Common variations

Skin tags on oraround ears

Ringing a bell by 6

inches from each ear.


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Ears

Signs of potentialdistress

or deviations from

expected findings: Ear placement low

Clefts present

Malformations Cartilage absent

Preauricular sinus


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Nose: Expected findings

Nostrils patent bilaterally

Obligate nose breathers

No nasal discharge


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Nose: Common variations

Sneezes to clear nostrils

Bridge appears absent

Thin white nasal mucus discharge


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Nose


from expected findings

Choanal atresia and discharge

Malformation

Nasal flaring beyond first few moments

after birth

M th & Th t


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Mouth & Throat:

Expected Findings Mucosa moist. Shortly after birth may visualize

sucking calluses on central portions of lips.

Mouth & Throat


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Mouth & Throat:

Expected Findings Palate high arched Uvula midline Minimal or absent

salivation

Tongue moves freely anddoes not protrude Well developed fat pads

bilateral cheeks Sucking reflex

Rooting reflex Gag reflex Extrusion reflex

Mouth & Throat:


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Mouth & Throat:

Common Variations

Epstein's pearls on ridges of gums


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Thrush : Candida infection : usuallyappear on the tongue and side of the

chicks are as white or as gray patches.


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Mouth & Throat



Cleft lip or cleft palate

Circumoral pallor Lip movement asymmetrical

Reflexes absent or incomplete

Protruding tongue

Candida Albicans

Diminished tongue movement


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Mouth & Throat

Candida Albicans Percocious teeth


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Physiologic function

Cardiovascular system

Blood Values : newborn blood volume is 80 110 ml per kilogram (300 ml )

Newborn common have high erythrocyte count 6 million percubic mm. and increase hemoglobin average of 17 18g/100ml and hemactocrit 4 and 50%

Newborn usually high in WBC at birth 15000 30000 cells

/mm3 . As high as 40000 if birth is stressful

Blood coagulation:most newborn have prolong coagualtion time


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Chest: Expected Findings

Evident xiphoid process

Equal anteroposterior and lateral diameter

Bilateral synchronous chest movement

Symmetrical nipples


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Chest: Common Variations

Witch's milk

Enlarged breasts

Accessory nipples

Fluid should neverexpressed frominfants breast.


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Urinary System

Average newborn void within 24 hours after birth. (24hours is the golden rule.

Male should void with enough force to produce projected

arc.

Female : produce a steady stream , not a continuousdribbling.

Usually light colored and odorless.Specific gravity : 1.008 1.0101st voiding: :pink or dusky because of uric crystal thatformed in the bladder in utero


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Gastrointestinal system

StoolStool passed within 24 hours after birth. Consist of meconium ( blackish green, odorlessmaterial

If not pass within 24 48 hours check for possibility of of

imperfobnate anus

2nd and third day stools ( transitional stool.)


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Newborn with bile obstruction:will have clay colored gray stools.

Because of bile pigments do not enterthe intestinal tract

Newborn under photo therapy

Bright green stools because of increase bilirubinexcretion.


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Immune system:

Passive anti bodies ( IgG ) againstpoliomellitis, measles diptheria,

pertusis ,chicken pox rubella andtetanus.


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Pallor : pallor is the result of anemia:

1. Excessive blood loss when the cord is cut.

2. addewquate floww of blood from the cord in to the infant at birth.

3. Fetal maternal transtransfusion

4. Low iron stores that caused by poor maternal nutrition during pregnancy

5. Blood incompatibility which large number of RBC were hemolzed in

utero.

7. Internal bleeding.

GRAY colored newborn generally indicates infection


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At about 20 mg / 100 mlKernicterus.


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Harlequin sign


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Twins transfusion phenomenon:


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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


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Abdomen: Common Variations

Small umbilical hernia


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Abdomen

Signs of potential distress or deviationsfrom 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


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Female Genitalia

Expected findings:

Edematous labia and clitoris

Labia majora are larger and surroundinglabia minora

Vernix between labia


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Female Genitalia

Common variations:

Hymenal tag

Pseudomenstruation

Smegma Increased pigmentation

Ecchymosis and edema after breech birth

"Red brick" pink-stained urine due to uric acidcrystals

G


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Female Genitalia


Labia fused

Fecal discharge from vaginal opening Imperforate hymen

Ambiguous genitalia

Widely separated labia

M l G i li


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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

M l G i li


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Male Genitalia

Common variations:

Prepuce ( foreskin ) covering urinarymeatus

Erections

Increased pigmentation

Edema and ecchymosis after breechdelivery

M l G i li


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Male Genitalia


Non palpable testes

Hypospadius ( ventral surface ) Epispadius ( dorsal surface )

Scrotum smooth

Ambiguous genitalia

B k d R t


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Back and Rectum

Expected findings:

Intact spine without masses or openings

Trunk incurvature reflex

Patent anal opening

"Wink reflex" present

B k d R t


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Back and Rectum

Signs of potential distress or deviationsFrom expected findings: Limitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cyst

E t iti


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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

E t iti


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Extremities

Palmar creasespresent

Sole creases present

Negative hip click Grasp reflex present

E t iti


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Extremities

Signs of potential

Distress or

deviations from

expected findings: Unequal tone

Asymmetrical movement

of extremities Polydactyly


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Syndactyly

E t iti


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Extremities

Syndactyly

Unequal leg length

Asymmetrical skin

creases posteriorthigh

Simean crease

Persistent cyanosis ofnail beds

E t iti


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Extremities

Dislocation of hip

Marked metatarusvarus

N l S t


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Neuromuscular System

Expected findings:

Maintains position of flexion

When prone, turns head side to side

Holds head and back in horizontal planewhen held prone

Ability to hold head momentarily erect



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Hypotonia

Quivering Limp extremities or straightening of extremities

Clonic jerking

Paralysis


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Newborn Physical Assessment by Ms. Mevelle L. Asuncion

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