Week 15: Newborn Assessment

Newborn Assessment Overview

Understanding a newborn's physiological responses and physical assessment findings is crucial for nursing care post-birth.

• Key assessment topics include APGAR Score, normal newborn appearance, New Ballard Score, vital signs and measurements, and care procedures.

• Normal newborn appearance can include wrinkly skin, acrocyanosis (blue hands and feet), milia (tiny white papules), erythema toxica (newborn rash), Epstein pearls (white/yellow cysts on gums), and lanugo (fine hair).

Newborn Priorities

• 1st Priority: Airway

• 2nd Priority: Warmth

Newborn Procedures in First Hours

• Procedures include suctioning, cord cutting, and APGAR scoring.

  • Parents can hold their baby skin to skin during these procedures.

  • Cord cutting is when the baby starts to work independently, breathing on their own, and AVA closes. 

  • Suctioning: Suction the mouth first before the nose to prevent aspiration. 

    • Done especially for C-section, as you are immediately removing them from the abdomen.

    • When delivering vaginally, the compression of contractions enhances the lung’s ability to remove secretions post-birth.

• AVA: The veins have stem cells (which can be donated) and have a jelly substance called Wharton's jelly that provides cushioning and support to the umbilical cord, protecting the blood vessels during pregnancy.

APGAR Scoring

• Purpose: Assess the newborn's adjustment to extrauterine life at 1 minute and 5 minutes after birth.

• Scoring Criteria:

  • 7 - 10: Indicates minimal or no difficulty adjusting.

  • 4 - 6: Indicates moderate difficulty.

  • < 4: Indicates need for resuscitation.

Criteria	Score 0	Score 1	Score 2
Respiratory Effort	Absent	Weak/Grunting	Strong Cry
Heart Rate	Absent	<100 BPM	>100 BPM
Muscle Tone	Floppy	Some Flexion	Active Movement
Reflex Response	None	Grimace	Cry on Stimulus
Color	Blue/Pale	Acrocyanosis	Pink

Newborn Vital Signs

• Heart Rate: 110-160 BPM

  • Tap your foot along to follow the heartbeat better. 

  • Transient murmurs are not abnormal. 

• Respiration: 30-60 breaths per minute

  • Short periods of apnea, no longer than 15 seconds. 

• Blood Pressure: 60-80 systolic, 40-50 diastolic

  • Typically not done unless in the NICU. 

• Temperature: 97.7 - 99.5 °F

  • Done in auxiliary. 

• Adjustments to extrauterine life involve rapid changes in the respiratory and circulatory systems, including the closure of the ductus arteriosus, foramen ovale, and ductus venosus.

HR Variability

• The average heart rate at 140 BPM at birth.

• Variations in heart rate include:

  • 70-100 BPM during sleep

  • 110-160 BPM when awake

  • Point of Maximum Impulse (PMI) is located at the 4th intercostal space to the left midclavicular line.

Temperature Regulation

• Temperature can drop due to exposure and skin heat-loss mechanisms, stabilizing within 8-12 hours post-admission.

  • A newborn should NEVER have a fever during the first couple weeks of life.

    • If this is the case, a spinal tap would be required.  

• Signs of infection include:

  • Temperature instability

  • Deviation >1°C (2°F) should be monitored at least once every 8 hours.

• Increased temperature may indicate overheating.

• A newborn’s temperature is initially high due to a warm uterine environment, which drops drastically after birth.

  • Skin-to-skin is the best way to maintain temperature. 

  • Large body surface area, limited ability to shiver, and underdeveloped subcutaneous fat contribute to a newborn's susceptibility to hypothermia, making careful monitoring of their temperature essential.

Mechanisms of Heat Loss

• Evaporation: Moisture loss from skin and lungs

  • Prevention: Dry the infant immediately after birth. 

• Convection: Heat loss to cooler air

  • Prevention: Keep the bed away from open windows.  

• Conduction: Heat loss to cooler surfaces

  • Prevention: Warm stethoscopes and other instruments before use, and place a blanket on a scale before weighing them. 

• Radiation: Heat loss to nearby cooler objects

  • Prevention: Keep the infant away from fans/AC. 

Respiratory Assessment

• Average of 30-60 respirations per minute with abdominal rising and falling during breathing.

• Signs of respiratory distress may include nasal flaring, retractions, grunting, tachypnea (>60 breaths/minute), and episodic breathing is normal.

• Count the respiratory rate for a full minute, and auscultate the anterior and posterior chest.

• Be mindful of color and heart rate changes in newborns.

Newborn Measurements

Weight

• Average: 3405 g (7 lb, 8 oz)

• Range: 2500-4000 g (5 lb, 8 oz to 8 lb, 13 oz)

• Physiologic weight loss: 5-10% for term newborns, up to 15% for preterm newborns

• Growth: 198 g (7 oz) per week for the first 6 months

Length

• Average: 50 cm (20 in)

• Range: 46-56 cm (18-22 in)

• Growth: 2.5 cm (1 in) per month for the first 6 months

Head Circumference

• Average: 33-35 cm (13-14 in)

• Range: 32-37 cm (12.6-14.6 in)

• Big heads because the brain is the fastest-growing muscle in the body. 

Chest Circumference

• Average: 32 cm (12.6 in)

• Range: 30-35 cm (11.8-13.4 in)

Newborn Appearance

• Typical features include:

  • Cone-shaped head due to molding during delivery

  • Fontanelles (soft spots on the skull)

  • Common rashes or red splotches

  • Milia (small white spots on the face)

  • Stork bites (salmon patches) and other birthmarks

Newborn Head Molding

• Caput Succedaneum: Edema that crosses suture lines

  • “It sucks”, doesn’t look good. 

• Cephalohematoma: Birth trauma with a collection of blood not crossing suture lines

  • Seen in children born using a vacuum or forceps. Greater concern!

Congenital Dermal Melanocytosis

• Formerly referred to as Mongolian spots.

• Benign, flat, dark blue-gray markings that are often found on the lower back and buttocks of newborns.   

  • They typically fade during the first few years of life and are more common in infants with darker skin tones.

  • Caused by melanocytes in deeper skin layers.

Normal Variants in Newborn

• Acrocyanosis: Normal blueness of hands and feet in the first 24 hours.

• Cyanosis: May also include circumoral cyanosis; it often indicates cooler temperatures.

  • Sign of poor oxygenation. This is alarming, especially if it’s seen around the tongue and the mouth. 

New Ballard Score

• Assesses neuromuscular and physical maturity of newborns.

• Total score indicates weeks of gestation (e.g., a score of 35 equals 38-39 weeks of gestation = approximately full-term).

  • The higher the score, the more maturity. 

  • Premature babies may have lower scores as they are “floppy”.

    • Heel to ear: means you could take a baby’s foot to their ear and measure their flexibility and muscle tone.

• Typically done when mom hasn’t done any prenatal care, if the baby is born too large or too small. 

Newborn Medications

• Newborns lack intestinal flora at birth (considered sterile until 7 days after birth); vitamin K is necessary for blood clotting.

• Vit K is administered to prevent hemorrhage and bleeding.

Eye Prophylaxis

• Administered to prevent gonococcal and chlamydia ophthalmia (the worst pink-eye infection that could lead to blindness if untreated).

• Options for administration:

  • 0.5% Erythromycin, 1 cm ribbon

    • Start at the inner to the outer canthus of the eye, applying the ointment gently along the lower conjunctival sac to ensure maximum coverage.

  • 1% Tetracycline, 1 cm ribbon

  • 1% Silver Nitrate Solution, 2 drops

Vitamin K

• A single injection is recommended for every newborn to prevent bleeding issues.

• Signs of Vitamin K deficiency may include:

  • Oozing from the umbilical stump

  • Blood in stool or vomit

  • Excessive bleeding from circumcision.

Hep B Vaccine

• Administered within 12 hours after delivery or before discharge.

  • Induces productive anti-hepatitis B antibodies. 

• Three doses are recommended at 0, 1, and 6 months for optimal immunity.

• Do it on the opposite leg from vitamin K to determine an allergic reaction.

Reflexes in Newborns

• Moro Reflex: Startle reflex

  • Spreading out of the arm and pulling in. 

• Rooting Reflex: Baby turns towards the cheek that is touched

• Tonic Neck Reflex: Head turns to the side, extending that arm and leg while flexing the opposite ones

• Other reflexes include the Grasp reflex and Babinski reflex (a positive Babinski reflex indicates immature neurological pathways).

  • Palmer: When they grab the finger of someone with their palm. 

  • Planter: put a finger and watch the baby’s toes wrap around the digit. 

  • Babinski: brush your thumb against the foot of the baby, and they fan out/curl their toes. 

Newborn Head-to-Toe Assessment

• Assess the head for shape, size, and abnormalities; note ear alignment (e.g., lower-set ears may indicate Down syndrome), and check nares functionality.

• Evaluate heart and lung sounds for rate (40-60 respirations per minute with short apnea periods) and any abnormal sounds.

• Inspect the back for dimples, which may suggest spina bifida.

• Check newborn reflexes, including Moro, rooting, and sucking, along with the palate.

• Look for crepitus, which can indicate fractures (common in shoulder dystocia), and count fingers and toes for abnormalities like polydactyly.

• Finally, inspect the diaper area, noting normal findings such as edematous male genitalia and pseudomenstruation in baby girls due to maternal hormones.

Infant Feeding

Breastfeeding Benefits

• Promotes immunity and nurtures the mother-baby bond.

• Cost-effective and environmentally friendly.

• Acts as a natural contraceptive and prompts oxytocin production.

• 8 or more feeds in 24 hours.

Formula Feeding

• Comes in three forms: powdered, concentrated, and ready-to-feed.

• Digests more slowly than breast milk, may spoil quickly, and should never be microwaved.

Newborn Care Procedures

• Procedures include:

  • Testing and health assessments.

  • Discharge teaching should cover safe sleeping positions, immunizations, feeding schedules, and car seat usage.

Newborn Screening Tests

• Involves a heel prick to test for metabolic conditions that may not show symptoms but require immediate treatment.

  • Usually done 24 hours after birth.

  • These tests are crucial for early detection of conditions such as phenylketonuria (PKU) and congenital hypothyroidism, ensuring timely intervention to prevent long-term complications.

• Hearing tests are performed shortly after birth.

Circumcision

• The surgical removal of the foreskin of the penis. It is essentially a cosmetic procedure.

• Vitamin K must be given before this procedure, and the baby must have voided at least once.

• Hemorrhage/bleeding is the most common complication. Other potential complications include infection and pain, which should be monitored closely during the recovery period.

• Reasons for circumcision:

  • Religious beliefs: A common practice in many faiths, including Judaism and Islam.

  • Cultural significance: Certain cultures view it as a rite of passage or tradition.

  • Medical reasons: Conditions like phimosis or recurrent urinary tract infections may necessitate circumcision.

• Given lidocaine or oral sucrose for pain management.

  • Oral sucrose given PO, 1-3 cc 2 minutes before a procedure. Analgesic effect may last 5-8 minutes from the first administration.

Complications in Newborns

• Common complications include neonatal substance withdrawal, hypoglycemia, respiratory distress syndrome, and infections.

• Wellness screening and management of jaundice and other conditions are essential for newborn health.

Diapering

• Proper diapering techniques help monitor input and output, ensuring the newborn is adequately hydrated and recognizing any potential health issues early.

  • Day 1-2: meconium

  • Day 3-4: transitional

  • Day 5+: breastfed baby (lighter colored poop).

• Improper cleaning can lead to UTI and even sepsis.

5 S’s of Soothing an Infant

• Swaddlie

• Suck

• Shush

• Swing/Sway

• Side/Stomach Position

Shaken Baby Syndrome/Abusive Head Trauma

• Caregivers should be educated on safe handling techniques to prevent injuries and promote healthy development in newborns.

• This may happen when you shake, drop, throw, or hit a baby.

• Long-term effects can be extremely serious:

  • Brain damage

  • Blindness

  • Deafness

  • Vegetative state

  • Paralysis

  • 25-30% of shaken babies die.

Sudden Unexpected Infant Death (SUID)

• The leading cause of death in infants under one year.

• Preventative measures include proper sleeping positions and avoiding overheating.

• Risk Factors:

  • Age (birth-6 months is at a higher risk), Sleep position, Preterm infant/low birth weight, Sibling death, Exposure to nicotine, Lower socioeconomics, Lack of prenatal care, Genetics, Bedding

• Prevention:

  • Tummy time, Breastfeeding, Checkups, Avoid overheating, Sleep, No smoking

  • Safe sleep (ABC’s)

    • Alone

    • Back

    • Crib

    • Pacifier use is recommended during sleep as the constant sucking reflex puts them in an easily arousable state of sleep instead of deep REM sleep.