Newborn Assessment

Normal Assessment:
- Axillary temperature: $36.5^{\circ}C-37.5^{\circ}C$ ( $97.7^{\circ}F-99.5^{\circ}F$ ).
Abnormal:
- Decreased temperature: May indicate a cold environment, hypoglycemia, infection, or a central nervous system (CNS) problem. Immediate actions include instituting warming measures and checking the temperature again in $30$ minutes. Blood glucose should also be checked.
- Increased temperature: May signify an infection or an excessively warm environment. Nursing interventions involve removing excessive clothing and checking for signs of dehydration.
Nursing Considerations:
- Actively look for signs of infection.
- Verify the temperature setting of the radiant warmer or incubator.
- Check the accuracy of the thermometer if the infant's skin feels unusually warm or cool to the touch.
- Report any abnormal temperatures to the physician promptly.

Normal Assessment:
- Heart rate: $120-160$ beats/min (bpm). This rate can be $100$ bpm when sleeping and up to $180$ bpm when crying.
- Rhythm is regular.
- Point of maximal impulse (PMI) is located at the third to fourth intercostal space (ICS), lateral to the midclavicular line.
- Brachial, femoral, and pedal pulses are present and equal bilaterally.
Abnormal:
- Tachycardia (heart rate greater than $160$ bpm): Can be associated with respiratory problems, anemia, infection, or cardiac conditions.
- Bradycardia (heart rate less than $120$ bpm): May indicate asphyxia or increased intracranial pressure (ICP).
- PMI shifted to the right: Suggests dextrocardia (heart on the right side) or pneumothorax.
- Murmurs: Can be normal and transient in newborns, or they may indicate congenital heart defects.
- Dysrhythmias: Irregular heart rhythms.
- Absent or unequal pulses: May be a sign of coarctation of the aorta (a narrowing of the aorta).
Nursing Considerations:
- Document the precise location of any detected murmurs.
- Immediately refer cases of abnormal heart rates, rhythms, sounds, or pulses for further evaluation.

Normal Assessment:
- Respiratory rate: $30-60$ breaths per minute, with an average of $40-49$ breaths per minute.
- Respirations are typically irregular, shallow, and unlabored.
- Chest movements are symmetric, and breath sounds are present and clear bilaterally.
Abnormal:
- Tachypnea (rapid breathing) or slow respiration.
- Nasal flaring, grunting, or gasping: These are signs of respiratory depression or distress.
- Periods of apnea longer than $20$ seconds, or apnea accompanied by changes in heart rate or color.
- Moist, coarse breath sounds (e.g., crackles, rhonchi): Indicate fluid in the lungs.
Nursing Considerations:
- Mild variations in respiration often require continued monitoring and usually resolve in the early hours after birth.
- If respiratory abnormalities are persistent or more than mild, nursing actions include suctioning, administering oxygen, notifying the physician, and initiating more intensive care.

Normal Assessment:
- Weight range: $2500-4000$ g ( $5$ lb, $8$ oz to $8$ lb, $13$ oz).
- A weight loss of up to $10\%$ is considered normal during the early days after birth.
Abnormal:
- High weight: May indicate a large for gestational age (LGA) infant or maternal diabetes.
- Low weight: Suggests a small for gestational age (SGA) infant, prematurity, multifetal pregnancy, or maternal medical conditions that affected fetal growth.
- Weight loss above $10\%$ : Points to potential dehydration or feeding problems.
Nursing Considerations:
- Monitor daily weights diligently while the infant is inpatient.
- Determine the underlying cause of any weight abnormalities.
- Monitor for complications commonly associated with the identified cause.

Normal Assessment:
- Length range: $48-53$ cm ( $19-21$ in).
Abnormal:
- Below normal length: Can be seen in SGA infants or with congenital dwarfism.
- Above normal length: Typically associated with LGA infants or maternal diabetes.
Nursing Considerations:
- Determine the cause when length is abnormal.
- Monitor for complications consistent with the cause.

Normal Assessment:
- Head circumference range: $32-36$ cm ( $12.5-14$ in).
- The head and neck together approximately account for one-fourth of the infant’s body surface area.
Abnormal:
- Small head circumference: May indicate an SGA infant, microcephaly, or anencephaly.
- Large head circumference: Can be a sign of an LGA infant, hydrocephalus, or increased intracranial pressure (ICP).
Nursing Considerations:
- Determine the cause when head circumference is abnormal.
- Monitor for complications commonly associated with the cause.

Normal Assessment:
- Chest circumference range: $32-36$ cm ( $12.5-14$ in).
- The head and neck together approximately account for one-fourth of the infant’s body surface area.
Abnormal:
- Small chest circumference: May indicate an SGA infant, microcephaly, or anencephaly.
- Large chest circumference: Can be a sign of an LGA infant, hydrocephalus, or increased intracranial pressure (ICP).
Nursing Considerations:
- Determine the cause when chest circumference is abnormal.
- Monitor for complications commonly associated with the cause.

Normal Assessment:
- Extremities are flexed, move freely, resist extension, and quickly return to a flexed state.
- Hands are usually clenched.
- Movements are symmetric.
- Slight tremors may be observed when the infant is crying.
- If the infant was delivered breech, their legs may be extended and stiff.
- The infant