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Neonatal Assessment Neonatal Assessment Child Health Nursing Child Health Nursing Ghada Abu Shosha Ghada Abu Shosha 2009 2009

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  • 1.Neonatal AssessmentChild Health Nursing Ghada Abu Shosha 2009

2. Neonatal Assessment

  • Assessment of the neonates is a critical function of the nurse immediately after birth. The purposes of neonatal assessments are to :
  • Identify prenatal influences on health status anddetermine risk status .
  • Provide baseline information on the infant for use as a reference marker .
  • Identify anomalies , actual health problems , or potential health problems .
  • Plan appropriate nursing care for infant and identify teaching needs of parents .

3. Neonatal assessment include

  • Evaluation of maternal , obstetric , and perinatal history .
  • Physical and behavioral assessment of the neonate .

4. Physical examination

  • The newborn clinical examination must be carried out in a regular sequence so that items are not forgotten
  • A useful approach is the head to toe technique
  • Whenever possible the infant should be examined in the presence of at least one parent

5. Apgar score

  • TheApgar scorewas devised in1952byVirginia Apgaras a simple and repeatable method to quickly and summarily assess the health ofnewbornchildren immediately afterchildbirth .

6. Apgar score

  • The Apgar score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two and summing up the five values.The resulting Apgar score ranges from zero to 10.

7. Apgar score Pink Body pink , extremities blue Blue or pale Color Cry Grimace No response Reflex irritability Active motion , extremities well flexed . Some flexion of extremities none Muscle tone Good , strong cry Weak cry Absent Respiratory effort Above 100 Below 100 Absent Heart rate2 1 0 Sign 8. Significance of Apgar score

  • Healthy newborn: 7-10 at both 1 and 5 minutes .
  • Moderately depressed newborn : 3-6 ( Need resuscitation )
  • Severely depressed newborn : 1-2 ( Intensive resuscitation )

9. Assessment of vital sign

  • temperature : the axillary method is the safest .
  • Normal axillary temperature is 36 36.5C
  • Heart Rate ( HR ) :
  • HR is counted for 60 seconds at the apex of the heart (Rangefrom 100- 160 b/m immediately after birth ) .
  • Respiratory Rate ( RR ) :
  • RR varies from 30- 60 b/m when the infant is not crying .
  • Blood Pressure( BP ) :
  • Not routinely assessedin healthy term infants .
  • The range of normal blood pressure in term infants is 60- 90mmhg for systolic pressure and 40 50 mmhg for diastolicpressure .

10. Assessment of Growth 11. Assessment of Growth

    • 1. Weight :
  • Birth weight is the baseline value for future assessment of weight .
  • Normal weight is 2500 4000 gm
    • 2. Length: 45 55 cm
    • 3. Head circumference :34 37 cm
    • 4. Chest circumference : 30 33 cm
  • An infant is considered appropriate for gestational age if weight , length , and head circumference are between 10 thand 90 th percentile .
  • Below 10 th percentile , the infant is termed small for gestational age
  • Above 90 th percentile , the infant is termed large for gestational age

12. Head Circumference 13. Assessment of Growth

  • During the first 3-5 days of life, infants usually lose between 5-10% of their birth wt as the kidneys excrete the small physiological excess of body fluid present at birth.
  • By the 10th day, birth wt is resumed. Then wt gain is usually between 180and 210g each week. Days of slow progress are followed by days of compensatory gain.

14. Measurement of the length

  • Measurement done in the supine position, head straight and legs fully extended, measurement between topmost point of the head and the heals.

15. Physical Assessment of the Newborn

  • General appearance :
  • Body symmetry , Pinkish skin color , responsiveness and crying . Well-flexed, full range of motion, spontaneous movement

16. 17. SKIN

  • Observation and palpation .
  • Color
  • Pallor - associated with low hemoglobin
  • Cyanosis - associated with hypoxemia
  • Plethora - associated with polycythemia
  • Jaundice - Elevated bilirubin
  • Lesions
  • Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks.
  • Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days.
  • Birth mark
  • Mongolianspots

18. SKIN

  • At 24 - 36 hours of age, skin flaky, dry and pink
  • in color Edema around eyes, feet, and genitals -Vernix caseosa -Lanugo - Turgor good with quick recoil - Hair silky and soft.
  • - Nipples present and in expected locations - Cord with one vein and two arteries Cord clamp tight and cord drying - Nails to end of fingers and often extend slightlybeyond

19. SKIN

  • Common variations
  • Acrocyanosis - result of sluggish peripheral circulation.


  • Mongolian spots

21. Mottling 22. Physiologic jaundice 23. Milia 24.

  • Erythema toxicum


  • Symmetric and round .
  • Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape of head. Check for encephalocoeles. Measure the head circumference.
  • Eyes
  • Cornea
  • Conjunctiva
  • Sclera
  • Iris
  • pupils

Head 26. Head

  • Expected findings
  • Anterior fontanellediamond shaped 3- 4cm,1.5-3cm- Posterior fontanelletriangular 0.5 - 1cm - fontanelles soft, firm and flat - Sutures palpable with smallseparation between each

27. fontanelles 28. Head

  • Common variations
  • Caput succedaneum

29. Common variations

  • Moldingof head may result in a lower head circumference measurement.

30. Molding of fontanels and suture spaces 31.

  • Signs of potential distress or deviations from normal findings
  • Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalhematoma
  • Closed sutures


  • Ears
  • Check for asymmetry, irregular shapes , or skin tags.
  • Pinna must be curved with firm cartilage with upper part of the pinna at or above outer canthus of the eye
  • Nose
  • Look for flaring of the alae nasi , symmetric , nasal discharge , patency of the nares .
  • Palate
  • Check for cleft lip and palate.


  • Mouth
  • Observe the size and shape of the mouth.
  • Mucosa and gum .
  • Tongue
  • Teeth
  • Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached.
  • Neck
  • Full movements
  • Palpate over all muscles, palpate clavicles for possible fracture.


  • Observe respiratory rate, respiratory pattern (periodic breathing, periods ofapnea). Observe chest movements for symmetry and for retractions. Listen for breathing sounds. Note that there may be some enlargement of the breasts secondary to maternal hormones.

35. Cardiovascular System 36. Cardiovascular System

  • Check baby's color for pallor, cyanosis, and plethora.
  • Measure heart rate, respiratory rate.
  • Check capillary refill. Check pulses, note character of pulses . Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, or other thoracic problem.
  • Note : rhythm and presence of murmurs that may be pathologic .


  • Note shape of abdomen.
  • Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually palpable, palpate for any abnormal masses. Auscultate for bowel sounds. Examine for hernias - umbilical or inguinal .

38. Genitourinary Exam

  • Kidneys
  • Examined by palpation deeply .
  • Male genitalia
  • Term normal penis is 3.60.7 cm stretched length. Inspect urethral opening,and shaft. Observe for hypospadias, epispadias. Inspect penis for edema, incision, bleeding. Full term infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes.


  • Female genitalia
  • Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal .

40. Extremities and Skeletal System

  • Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.
  • Upper extremity
  • Look for clavicular fracture, Inspect creases and fingers.
  • Lower extremity
  • Inspect posture . Do Ortolani maneuver to check for congenital hip dislocation. Check toes.

41. Extremities

  • Expected findings
  • Maintains posture of flexion Equal and bilateral movement and tone Full range of motion all joints- Ten fingers and ten toes
  • Palmer creases present
  • Negative hip click Grasp reflex present

42. Dislocation of hip 43. Neonatal Primitive Reflexes 44. Reflexes

  • include the Moro , startle , palmer and planter grasps, sucking and rooting and swallowingreflexes, tonic neck reflex ,stepping , and babinskisign .

45. Reflex s

  • Moro Reflex : Sudden change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers ,with index finger and thumb forming c shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry;disappears after age 3-4months.
  • Palmer grasp : touching palm of hand near base of digits cause flexion of hands,lessens after age 3 months.
  • planter grasp : touching feet near base of digitscause flexion to toes,lessens by 8months age


  • Babniski reflex : stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflexdisappears after age 1 year
  • Rooting reflex : touching the cheek along side of mouth causes infant to turn head toward that side and begin to suck ; disappear at age 3-4 months, may persist for up to 12 months.


  • Sucking reflex : infant begins sucking movement in response to stimulation ; persists though out infancy , even without stimulation ,such as during sleep.
  • Asymmetric tonic neck reflex : when infant head is turn to one side, arm and leg extend on that side, and opposite arm and leg flex ,disappears by age 3-4 months


  • Swimming reflex : If you were to put a baby under six months of age in water, they would move their arms and legs while holding their breath. This is why some families believe in swim training for very little babies. It is not recommended for you to test this reflex at home for obvious safety reasons.
  • Dolls eye reflex: as a head of infant moved slowly toright or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation developed, if persists indicate neurological damage.


  • Dance or step reflex :if infant is held so that the sole of foot touch a hard surface there is flexion and extension of the leg stimulating walking.disappear after age 3-4week.
  • Startle reflex : sudden loud noise causes abduction of the arms wit flexion of elbow, hand remain clenched ; disappears by age of 4 months

50. Moro Reflex 51. Palmer grasp 52. planter grasp 53. Babniski reflex 54. Rooting reflex 55. Sucking reflex 56. Asymmetric tonic neck reflex 57. Swimming reflex 58. Dance or step reflex 59. Startle reflex