Week 15: Newborn Assessment

Newborn Assessment Class Notes

Objectives

  • Review the health promotion and maintenance of a newborn

  • Assist clients with performing and learning newborn care

  • Techniques of physical assessment

  • Non-pharmacological comfort interventions

  • Nutrition

  • Infant safety & nursing care and discharge teaching

  • Assessment and management of newborn complications

Newborn Assessment Overview

  • Understanding physiological responses in a newborn and physical assessment findings is imperative for providing nursing care following birth.

  • Key Topics:

    • APGAR Score

    • Normal newborn appearance

    • New Ballard Score

    • Newborn Vital Signs & measurements

    • Procedures and baby care

  • Skin is wrinkly, as it is sitting in amniotic fluid. 

  • Blue hands and feet (acrocyanosis), as their body’s perfusion is focused on the vital organs. 

  • Tiny white papules are normal (milia). Erythemia toxica, newborn rash. Epstein pearls, white/yellow cysts that are on the gums, not natal teeth. 

  • Lanugo, fine hair that covers the fetus, is often present and sheds shortly after birth.

Normal Newborn Appearance

  • 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.

APGAR Components and Scoring

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

Normal 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.

  • Transient heart murmurs can be normal.

Heart Rate 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.

Physical Assessment: 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.

Newborn Thermoregulation

  • 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 include:

    • 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. 

  • Preventive measures for each mechanism are necessary.

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.

Key Techniques for Assessment

  • 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

  • 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. 

  • View handout!!

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.

Hepatitis 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

  • Head: Observe the shape and size of the head, checking for any abnormalities such as asymmetry or malformations.

    • Ears that are not aligned with the eyes (lower onset ears) would indicate Down syndrome.

    • Starbiusis/Lazy Eyes: not abnormal in newborns.

    • Compress one nostril at a time to assess nares functionality.

  • Listening to heart and lung sounds: Evaluate the heart rate and respiratory rate (40-60, with short periods of apnea) while observing for any abnormal sounds or difficulties in breathing.

  • Look at their back: dimples may indicate potential spina bifida or other neural tube defects, while a smooth, symmetrical back is a normal finding.

  • Assessing reflexes: Check for other newborn reflexes, such as the Moro reflex, in which the baby startles in response to a sudden noise or movement, and the rooting reflex, in which the baby turns their head towards a stimulus when the cheek is stroked.

    • Assess sucking reflex and palate.

  • Crepitus: could indicate bone fractures, seen in shoulder dystocia babies.

  • Count fingers and toes, indicate any abnormalities; an extra digit (polydactyly) could be common if genetic and can be removed.

  • The diaper area is inspected last.

    • Boys may be edematous in their genital area.

    • Psdeuomenstration: Presented due to mom’s hormones, and you’ll find some blood in the baby girl’s diaper within the first week of life.

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 (I’s & O’s)

  • 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.

Car Seat Safety

  • Emphasize rear-facing as long as possible.

  • Encourage parents to have installations checked at certified stations.

Ethical and Practical Implications

  • Educating parents on newborn care is critical for preventing complications and ensuring safe developmental practices.

By capturing all of this information in a structured manner, students can have a comprehensive understanding of newborn care and assessments necessary for nursing practice.