NRS 3026 Chapter 20 Assessment of the Newborn

history to review

data on pregnancy, labor, delivery

maternal age, health problems, any complications

narcotic analgesics late in labor affect respirations

preterm infants and surfactants

airway assessment

RR, breath sounds (usually irregular)

respiratory distress sounds: tachypnea, retractions, nasal flaring, cyanosis, grunting

color: pallor, ruddy, capillary refill

cardio assessment

heart sounds, brachial and femoral pulses, BP (only in NICU)

thermoregulation

take temperature after bath

set warmer controls to regulate heat production

reassess every 30 mins until stable

general assessment head to toe

Head: molding, fontanels, caput succadaneum, cephalohematoma

Face, neck, clavicles (rotate)

Umbilical cord, Hips

extremities, hands and feet for acrocyanosis

measurements: weight, length, head, chest

babinski reflex

bottom of foot is stroked upward from the heel

big toe dorsiflexes (bends backward) while the other toes spread

rooting reflex

when you stroke the baby’s mouth, it will turn its head and open its mouth

moro reflex

a sudden loud noise or unexpected movement causes the infant to extend arms, palms up before returning to the body

tonic neck reflex or fencing

if the head is turned to the right, the right leg and arm will straigthen while the left side bends

GI system assessment

mouth, suck, initial feeding, abdomen (soft), stools

GU system assessment

kidney, urine (avg wet diapers, uric acid crystals (little red)), genitalia

skin assessment

mottling, vernix caseosa, birth marks, delivery marks, scratches

lanugo

hair on body

milia

white dots on face

peeling

skin on hands do this, it is common

erythema toxicum

red rash normal

ballard score for gestational age

neuromuscular: posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear

physical characteristics: skin, lanugo, plantar surface, breasts, eyes, ears, genitals

gestational age/infant size: SGA <10%, LGA >90%