Newborn Head to Toe Assessment
Assessment Technique and Expected Findings
Posture
Technique:
Inspect prior to disturbing with other assessment components.
Findings:
Flexed extremities that move freely, resist extension, and return quickly to the flexed state.
Hands usually clenched.
Movements symmetric with slight tremors noted when crying.
Newborn “molds” body to caretaker’s body when held, responds by quieting when needs are met.
For newborns born in breech position, expect extended, stiff legs.
May exhibit temporary facial asymmetry or resistance to extension of the extremities due to prenatal pressure on limb or shoulder.
Abnormal findings may include:
Hypotonia: decreased muscle tone.
Hypertonia: increased muscle tone.
Limited or unequal movement.
Possible seizure activity.
Skin
Technique:
Inspect semi-naked in a well-lit room, observing for color, jaundice, birthmarks, or bruising.
Assess skin turgor by gently pinching the inner thigh.
Findings:
Generally pink (erythematous immediately after birth) but varies with race and ethnicity.
Observe for:
Peripheral acrocyanosis: bluish or purple coloring of the hands or feet.
Small amounts of lanugo over shoulders, sides of the face, forehead, and upper back.
Skin turgor typically normal with quick recoil.
Some cracking and peeling of skin.
Mottling, which may be normal.
Telangiectases: “stork bites,” infantile hemangiomas.
Milia: small white cysts on the skin.
Erythema toxicum: a newborn rash.
Petechiae in the presenting area.
Ecchymoses that may result from forceps delivery.
Slate gray nevus: known as a Mongolian spot.
Nevus vascularis: a strawberry hemangioma.
Cyanosis of mouth indicating possible hypoxia.
Pallor indicating anemia or hypoxia.
Facial bruising may occur due to nuchal cord.
Ruddy appearance may indicate polycythemia.
Mottling may indicate cold stress, hypovolemia, or sepsis.
Gray coloration (hypoxia, hypotension).
Jaundice noted on skin or sclera, especially within the first 24 hours.
Generalized petechiae or ecchymoses.
Nevus flammeus.
Hemangiomas.
Edema of hands, feet, tibia, or periorbital region.
Possible skin tags or webbing.
Lack of subcutaneous fat may be observed.
Head
Technique:
Inspect size, shape, symmetry, pattern, and distribution of hair.
Palpate for head, sutures, and fontanels.
Findings:
Molding of the head is common.
Anterior fontanel: diamond-shaped, approximately 5 cm, soft, and flat; may bulge slightly with crying.
Posterior fontanel: triangular and measures 0.5–1 cm.
Sutures palpable with small separation between each.
Hair typically appears silky and soft with individual strands of hair noticeable.
Possible findings may include:
Overriding sutures.
Slight asymmetry.
Caput succedaneum: swelling from the pressures of delivery.
Cephalohematoma: blood between the skull and periosteum.
Macrocephaly: abnormally large head.
Microcephaly: abnormally small head.
Severe molding due to birth trauma.
Indentation indicating fracture.
Bulging or full fontanel, or a depressed fontanel.
Widely spaced sutures indicating potential issues.
Abnormal hair growth patterns possibly indicating genetic abnormalities.
Hard, ridged area not resulting from molding could suggest craniosynostosis (premature closure of sutures).
Facial asymmetry may also be noted.
Eyes
Technique:
Inspect appearance, symmetry, movement, and assess pupillary response, as well as the red reflex.
Findings:
Eyes should be symmetric in size, shape, and movement.
Pupils are equal and reactive to light.
The doll's eyes sign should be present; the red reflex is observed.
Minimal tearing is typical.
Potential abnormal findings include:
Subconjunctival hemorrhage or edema of eyelids from birth pressure.
Transient strabismus (crossed eyes) or nystagmus (involuntary eye movement).
Signs of inflammation or drainage must be evaluated.
Persistent tearing is of concern.
Lens opacity or absent red reflex indicates potential problems.
Jaundiced sclera indicating liver issues.
Blue sclera indicating connective tissue disorders.
Agenesis: absence of structures.
Unequal, constricted, or fixed pupils.
Persistent strabismus or signs of the doll's eyes.
Sunsetting may indicate increased intracranial pressure.
Ears
Technique:
Observe size, location, asymmetry, and conduct hearing assessments.
Note that most newborns undergo a hearing screen before hospital discharge.
Findings:
Ears are well-formed and complete.
The region where the upper ear meets the head is in line with the outer canthus of the eye.
Startle response to loud noises or voices is typical.
Abnormal findings may include:
Agenesis: absence of structures.
Low-set ears.
Presence of skin tags, preauricular sinus defects, or dimples.
Lack of response to sound may indicate hearing issues.
Nose
Technique:
Observe shape, placement, patency, and configuration of the nose.
Findings:
Nose should be midline and symmetric.
Minimal drainage is normal.
Nostrils should be patent bilaterally.
Possible variations include:
Slightly flat or deviated nose after birth.
Copious drainage may indicate obstruction.
Malformation or asymmetry requires further assessment.
Flaring of nares may indicate respiratory distress.
Blockage of one or both nasal passages may affect respiration.
Mouth (Including Feeding)
Technique:
Inspect lips, gums, tongue, uvula, and palate.
Assess sucking, rooting, and gag reflexes.
Observe for feeding and signs of hypoglycemia.
Findings:
Lips, gums, and tongue should be pink and moist.
Soft and hard palate must be intact.
Uvula should be midline.
Size and movement should be symmetric.
Normal reflexes include sucking, rooting, swallowing, and gag reflexes.
Feeding should show good coordination of suck, swallow, and breath.
Possible abnormal findings include:
Precocious teeth.
Epstein pearls (small cysts on the gums).
Ankyloglossia (short lingual frenulum).
Gross anomalies in placement, size, or shape.
Cyanosis or circumoral pallor indicating distress.
Asymmetry of movement of lips.
Suck reflex may be weaker in preterm newborns.
Signs of choking, coughing, or cyanosis during feedings.
Macroglossia (large tongue) or micrognathia (small jaw).
Thrush (oral yeast infection).
Cleft palate issues can affect feeding and require assessment.
Signs of hypoglycemia include jitteriness, poor muscle tone, diaphoresis, tachycardia, tachypnea or dyspnea, high-pitched cry, lethargy, and irritability.
Neck/Clavicles
Technique:
Inspect the neck and assess range of motion and symmetry.
Inspect and palpate clavicles.
Findings:
Usually, a short neck with full range of motion is observed.
The head should be held midline.
Newborns can raise their head when placed prone.
Clavicles should be intact.
Abnormal findings may include:
Transient positional deformity, but there should be passive movement of the head.
Webbing between the occiput and shoulders.
Restricted range of motion may indicate issues.
Presence of lumps, crepitus, or crying with clavicle palpation may indicate fracture.
Chest
Technique:
Inspect and palpate the chest.
Assess respiration, work of breathing, and auscultate heart sounds including rate, rhythm, and any murmurs present.
Findings:
Chest typically appears barrel-shaped and symmetric.
Nipples should be present and located appropriately.
Chest expansion should be symmetric and synchronized with abdominal movements.
Breath sounds should be clear.
Normal heart sounds should be S1 and S2 without murmurs.
The xiphoid process may be prominent.
Breast modules may be present (approximately 6 mm).
Breast engorgement may cause white nipple discharge.
Abnormal findings may include:
Lumps, swellings, or tenderness in the ribs.
Crepitus, indicating fractures or movement of bones associated with trauma.
Any malformations or bulging in the chest.
Unequal movements during respiration.
Retractions or respiratory distress should be evaluated urgently.
Supernumerary nipples or widely spaced nipples may signal need for further evaluation.
A murmur indicates abnormal blood flow through the heart, but most murmurs are temporary and benign.
Abdomen
Technique:
Inspect and palpate the abdomen and umbilical cord.
Auscultate bowel sounds.
Findings:
Abdomen appears rounded and prominent.
Liver palpable 1–2 cm below the right costal margin indicates normality.
Umbilical cord should contain two arteries and one vein, with the clamp tight and drying.
Bowel sounds should be present.
Possible abnormal findings include:
Reducible umbilical hernia.
Abnormalities in the umbilical cord such as one artery, meconium stain, bleeding, redness or drainage, herniation.
Gastroschisis: birth defect of the abdominal wall allowing organs to protrude.
Look for sunken or scaphoid appearance of the abdomen indicating potential issues, along with bowel sounds in the chest suggesting a diaphragmatic hernia.
Enlarged liver or presence of abdominal masses need further assessment.
Absent bowel tones warrant concern for intestinal blockage or motility issues.
Genitalia
Female
Technique:
Inspect labia majora, labia minora, clitoris, vagina, and urinary meatus.
Findings:
Clitoris and labia majora may be edematous.
Labia minora can protrude over labia majora.
Urinary meatus and vagina must be present, and urine should be passed within 12–24 hours.
Abnormal findings include:
Vaginal bleeding (pseudomenstruation).
Hymenal tags.
“Brick dust” staining of the diaper indicating uric acid crystals.
Male
Technique:
Inspect the penis, urinary meatus, scrotum, and testes.
Palpate testes and assess cremasteric reflex.
Findings:
Prepuce is typically nonretractable.
Meatus should be at the tip of the penis.
Rugae should be present on the scrotum.
Testes must be palpable within the scrotal sac bilaterally, and urine should be passed within 12–24 hours.
Possible abnormal findings include:
Scrotal edema and ecchymosis from breech birth.
Hydrocele: a small, noncommunicating fluid-filled sac around the testicle.
Testes may be palpable in the inguinal canal.
“Brick dust” staining of the diaper indicating uric acid crystals.
Decreased urine output may signal renal impairment or dehydration.
Ambiguous genitalia needs a thorough assessment for potential disorders.
Stenosed meatus or bladder exstrophy require urgent intervention.
Anus
Technique:
Inspect anus and assess sphincter tone.
Findings:
Anus present and patent; sphincter tone is normal.
Meconium stool should pass within 24–48 hours.
Abnormal findings may indicate:
Imperforate anus without fistula.
Rectal atresia or stenosis requiring surgical evaluation.
Absent anal opening or failure to pass stool indicates emergency.
Extremities
Technique:
Inspect and palpate all extremities, noting symmetry and muscle tone.
Assess flexion, range of motion, and symmetry of all joints.
Inspect digits on hands and feet, assess peripheral pulses and capillary refill.
Findings:
Extremities should be symmetric with normal muscle tone.
Joints exhibit full range of motion and symmetrical contour, with spontaneous and symmetric movement.
Correct number and formation of fingers and toes must be verified.
Peripheral pulses should be strong and equal bilaterally; capillary refill should be brisk.
Possible abnormal findings include:
Transient positional deformities.
Slight tremors may be apparent, which should be evaluated.
Acrocyanosis: a bluish color of the extremities.
Limited range of motion or asymmetry is concerning.
Hypotonia or hypertonia indicates potential issues needing further assessment.
Femoral pulses weaker than brachial pulses could indicate cardiac anomalies.
Signs of fracture: crepitus, redness, lumps, or swelling.
Abnormal conditions may/may not include polydactyly, syndactyly, fusion of digits, or absence of digits.
A single transverse palmar crease (simian crease) may suggest Down syndrome.
Club foot requires referral for orthopedic evaluation.
Hips and Spine
Technique:
Inspect gluteal fold, thigh folds, leg length, and range of motion of hips.
Inspect and palpate the spine, shoulders, scapulae, and iliac crests.
Findings:
Gluteal and thigh folds appear symmetric; hips exhibit full, symmetric range of motion.
Spine should be straight and easily flexed; infant momentarily raises and supports head.
Shoulders, scapulae, and iliac crests should also be symmetric.
Possible abnormal findings include:
Hip dysplasia exhibiting unequal thigh folds, gluteal folds, or leg length, as well as reduced or unequal motion capabilities.
Limited spinal movement may imply structural issues.
Presence of meningocele or myelomeningocele may be suspected.
Pigmented nevus with hair tuft along the spine requires evaluation.
Pilonidal dimple or sinus presents additional assessments.
Neurologic
Technique:
Assess presence and strength of reflexes.
Observe for tremors and jitteriness.
Assess cry quality and whether the infant is consolable.
Findings:
Reflexes should be present and strong.
Absence of tremors or jitteriness is expected.
A lusty cry indicates good respiratory effort; should console easily and exhibit normal molding when held.
Possible atypical findings:
Shrill, high-pitched, hoarse, catlike cry may indicate neurological issues.
Stiffening and pulling away or arching when held warrants further neurological assessment.
Excessive irritability can be a sign of underlying pathology.