Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching

Assessment Items	Norms	Abnormalities	Anticipatory Guidance and Health Teaching	Further Action Required
General Health	- well-flexed, full range of motion, spontaneous movement - legs extended with frank breech	- Any abnormalities assessed from health screenings or medical appointments are followed up with appropriate care provider - posture limp - asymmetry of movement - persistent tremor and/or twitching		- call medical care provider immediately if abnormalities exist
Vital Signs
1. Temperature	- axillary: 36.5-37.5C (97.8-99.5F) degrees & stable - crying may temporarily elevate temperature	neonatal sepsis: at present gram negative organisms Group B Streptococcus is the most common causative agent of earl onset sepsis followed by e-coli. -early onset occurs with in 7 days of life; late onset occurs one week to 3 mos -early symptoms are vague & frequently nonspecific but include: apnea, Jaundice within first 24 hours tachypnea, temperature instability, tachycardia, lethargy and poor feeding -later symptoms are petechiae, seizures, enlarged liver & spleen and conjugated hyperbilirubinemia	- teach parents how to take an axillary temp. when signs of illness are present - use rectal temp only at the instruction of the medical care provider - reinforce that newborns have little fat & can't at first readily regulate their own temp. Avoid excessive layers of clothing when surrounding temp. is warm. A rule of thumb is to dress infant 1 extra thin layer more than parent(s) is wearing - call medical provider if newborn temp is 100.4 (38c) or higher	-Assess temperature, refer to medical care provider if abnormality above or below the norm observed
2. Heart rate	- 120 – 160 BPM - Heart rate range to 100 when sleeping to 180 when crying - Color pink with acrocyanosis - Heart rate may be irregular with crying	- murmurs may be due to transitional circulation - deviation from range - faint sound		Although murmur may be due to transitional circulation all murmurs must be followed up and reported to the medical care provider
3. Respirations	30 – 60 breaths per minute	- asymmetrical chest movements - apnea >15 seconds - diminished breath sounds - seesaw respirations - grunting - nasal flaring - retractions - deep sighing - tachypnea - respirations > 60 - persistent irregular breathing - excessive mucus - persistent fine crackles - stridor	- Teach parents to call medical care provider if infant/newborn has any symptoms of retractions, nasal flaring, shallow or excessively rapid breathing, deep sighing, excessive mucus or stridor
4. Blood pressure	Not done regularly
General Measurements
Head Circumference	- 32 to 37 cm - head should be 2cm to 3cm larger than the chest - molding of head may yield a lower head circumference measurement - molding may last several days & returns to normal with in 2-3 days after birth - head and chest may measure equal for first 24 – 48 hours of life	- deviation from range and/or unexpected changes in size or shape	- discuss belly time when baby awake to prevent molding and to promote strength.
Chest Circumference	- 30.5 cm to 33.5 cm	- deviation from range
Weight	- 10% weight loss over 1st 3 days of life is normal	- weight loss >10%	- assure that the same calibrated scale is used if the newborn's weight requires monitoring	- Call medical care provider if wt loss >10% in first 1-3 days or if premie with any poor wt gain (less than 30 grams a day for first month)
Length	- 18 to 21 inches			- Measure from heel to crown
Skin
-color	-Caucasian -Pinkish; Blacks –Reddish Brown cyanosis of hands and feet (acrocyanosis is seen in the 1st 24-48 hrs of life & may last up to 10 days); mottling -circumoral cyanosis w/ crying, possibly w/ feeding -no pallor -physiologic jaundice occurs after the 1st 24 hrs of life: onset: by end of second, beginning of third day & ending around seventh day progression: jaundice first appears on the head and face, progressing downward to the trunk and extremities & finally to the sclera of the eyes course: intensity decreases symptoms: none	- cyanosis: at rest/quiet, between feedings, cyanosis of torso is persistent - pallor - yellow vernix - forceps marks - jaundice: onset: within 24 hrs of birth or after 7th day in full-term newborn & 14th day in pre-term newborn course: intensity persists or increases symptoms: poor suck, eating less, irritable, vomiting, decreased activity (lethargy), sleeping long periods	-inform parent(s) that 50% of newborns develop jaundice on the 2nd, 3rd, or 4th day of life but very important to inform their medical care provider if jaundice develops -teach parent(s) physiologic course of jaundice and how to assess for jaundice by observing the color of skin & sclera for yellow tinge & if yellow tinge present note its depth -reinforce touchpoint: “autonomic regulation” color changes can be sign of stress.	-Assess skin color; refer to medical care provider if abnormally observed -if jaundice appears during the 1st 24 hrs of life, it may indicate the presence of an underlying illness. Notify medical care provider immediately
-hydration	- skin falls quickly into place w/o residual marks after gently lifting up a fold of skin -localized edema may be noted in a presenting part due to trauma -swelling of breasts & genitals common (due to hormones)	-tenting of skin (dehydration) -edema (generalized or localized other than in a presenting part)	-Breast feed 10-12x/24hrs -Formula feeding adequate amounts; Formula preparation	-Assess skin hydration, refer to medical care provider if abnormality observed -Assess fluid intake
-general appearance	-normally skin is dry & peeling vernix caseosa-cheesy white layer of skin formed in uterus and lubricates the skin of the newborn; milia-multiple yellow/pearly white papules, located on face;due to retained sebum; disappear in a few weeks miliaria (heat rash) -superficial grouped vesicles w/o erythema or red grouped papules; usually found in forehead skin, scalp, creases or groin area caused by obstruction of sweat ducts from excessively warm & humid environment erythema toxicum - blotchy, red papule w/ a central yellow/white elevations; located generally on face, trunk or extremities; appear suddenly on 1st-2nd day & disappear in a few hrs to a few days; often called newborn rash or fleabite dermatitis. -forcep marks on face, cheeks, jaw, usually disappear in a day or two -stork bites (telangiectatic nevi): pale pink or red spots found on the eyelids, nose, lower occipital bone & nape of neck; usually fade by 2nd birthday -strawberry mark (nevus vasculosus): raised, clearly delineated, dark red, rough surfaced birthmark commonly found in head region. Grow (often rapidly) for several mos and become fixed in size by 8 mos. Then begin to shrink & resolve spontaneously. About 90% cases resolved by 9 yrs of age. -Mongolian spots: dark blue or purple, bruise like spots usually over sacrum, found in darker complexioned infants, gradually fade during 1st or 2nd year of life -port wine stain (nevus flammeus): non-elevated, red to purple area (in infants of African descent it may appear as purple-black stain) & commonly appears on the face. It does not grow in size, does not fade w/ time and does not blanch as a rule.	-petechiae, other than on presenting part -diaper rash that persists or gets worse after following steps (listed under anticipatory guidance & health teaching) to alleviate the problem -skin breakdown and infection; redness and rashes (other than norms described), blotches or drainage	- skin of the term or post-term newborn has less vernix and is frequently dry; peeling is common, especially on the hands & feet - give guidance re diaper rash: keep affected area dry by changing diaper frequently, clean baby well & air drying area; changing disposable diaper brands may help. Baby powder (or cornstarch) is not recommended since it may cake with urine and irritate the skin. - - ointments that provide a barrier such as zinc oxide, A&D ointment, or petroleum jelly may be helpful - do not use perfumed detergents for clothing. - assure parents that erythema toxicum is normal & appears suddenly on the 1st - 2nd day of life and can disappear in a few hours to a few days - birthmarks are frequently a cause of concern for parents. The mother may be especially anxious, fearing that she is to blame; provide appropriate information about the cause and course of birthmarks and dispel any misconceptions - birthmarks may rarely be subject to trauma with ulceration & bleeding. - reassure Mongolian spot is normal - measure Mongolian Spots for future reference. This has been used to disprove abuse when found in childhood records.
Head
Symmetry/Shape	- anterior fontanel diamond shaped 2-3 - 3-4 cms - posterior fontanel triangular 0.5 - 1 cm - fontanels soft, firm and flat - sutures palpable with small separation between each - molding of fontanels & suture spaces - minor asymmetry is common and should equalize by approximately 4 months - cephalhematomas emerge between the 1st & 2nd day, may be unilateral or bilateral and do not cross suture lines - caput succedaneum (the fluid in a caput) is reabsorbed with in 12 hrs or a few days after birth - clean scalp	- fontanels that are bulging or depressed - hydrocephalus - macrocephaly - cephalhematoma - closed sutures - crackle cap (refer if persistent to r/o eczema)	- reassure parent(s) re minor asymmetry-explain that skull bones are not fixed at birth so that: (a) baby's head can adjust to birth passage during labor; (b) during infancy the skull grows rapidly to accommodate the brain; (c) discuss changing baby's position, when awake, because lying in one position over a period of time will cause flattening. Baby should always sleep on back. Allow for belly time when awake. - if baby has a cephalhematoma, reassure parent(s) that they are relatively common on vertex births and may disappear with in 2-3 weeks or slowly over subsequent months
Eyes	- slate gray or blue eye color - no tears - fixation at times - with ability to follow objects to midline - red reflex - blink reflex - distinct eyebrows - cornea bright and shiny - pupils equal and reactive to light - bruised and/or puffy eyelids are normal - sclera white to bluish white; slightly brownish frequent in newborns of African descent - small conjunctiva, sclera & retinal hemorrhages are common	- excessive tearing or discharge - infection: sore, red swollen lids, conjunctivitis, purulent discharge - blocked tear duct; unilateral tearing with chafing of cheek jaundice (sclera) - opacity - anomalies; such as eyes wide apart (spacing) - prominent epi canthal folds - bulging eyeballs	- tearing begins after 2-3 months of age - ask what parent(s) was taught in hospital re eye care, explain no need to wash out baby's eyes with any solution; wash gently over eyes with cotton ball, using separate balls for each eye to remove any secretions on outside - if needed, demonstrate to parent(s) how to massage a blocked tear duct - reassure parent(s) that puffy and/or bruised eyelids are normal after birth
Ears	- pinna top on horizontal line with outer canthus - flexible pinna with cartilage present - loud noise elilcits startle reflex - passed hearing test prior to hospital discharge - skin tags on or around ears can be a normal variation	- ear placement low - preauricular sinus - clefts present - malformations - cartilage absent - discharge	- ask parent(s) if baby passed hearing test in hospital and if baby reacts to sounds such as voices, music, etc. - discuss risk factors for hearing loss & preventive measures; if at any time they suspect a problem w/ hearing recommend they discuss with their medical provider - teach sponge outer ear only; never put anything in canal (including Q tips)
Nose	- Obligate nose breather (breathes easily through either nostril with lips closed) - nostrils patent bilaterally (may have temporary plugging) - sneezing is a natural reflex which clears nostrils - no dischcarge - symmetrical and placed vertically in midline	- obvious discharge - constant nasal blocking - nasal flaring - choanal atresia and discharge - malformation	- teach sneezing is not a cold; simply a way of cleansing nostril-wipe off only visible secretion. Not to use Q-tips. - ask mother what she was taught in hospital re bulb syringe & if she is comfortable using the bulb syringe; instruct if necessary
Mouth & Throat	- moist mucosa - sucking calluses on central portions of lips - chin is poorly developed in relation to face - frenulum allows good mobility of tongue; able to grasp nipple - intact soft/hard palate - palate high arched - epstein pearls - uvula midline - tongue moves freely and does not protrude - well developed fat pads bilateral cheeks - sucking reflex - rooting reflex - gag reflex	- small lower jaw - cleft palate - thrush (whitish patches which spread rapidly & don't rub off w/o causing redness or bleeding) - protruding tongue - diminished tongue movement - circumoral pallor - lip movement asymmetrical - Precocious teeth - tongue tie - large tongue	- explain small chin enables a baby to fit the breast comfortably - glassy white look to roof of mouth is normal (cartilage) - may be Candida - check mother’s nipples if breastfeeding; if bottle feeding boil the rubber nipples - suggest parent(s) discuss w/ their medical care provider if baby has tongue-tie (if they have concerns)
Neck	- contraction of the shoulder & arm muscles, followed by flexion of the neck and minimal head lag when pulling infant from a supine to sitting position - short and thick - turns easily side to side - clavicles intact - tonic neck reflex present - neck-righting reflex present - some head control	- more than 45 degree lag - anomaly present e.g. web neck - torticollis-stiff neck drawing head to one side - resistance to flexion - large fat pad on back of neck - palpable crepitus, movement with palpation of clavicle
Chest	- evident xiphoid process - equal anteroposterior and lateral diameter - bilateral synchronous chest movement - symmetrical nipples -two nipples -may have some breast enlargement	- asymmetrical chest movements - sternum depressed - marked retractions - absent breast tissue - flattened chest - supernumerary nipples - nipples widely spaced - bowel sounds auscultated	-explain breast enlargement is normal & reason why it occurs: mother's hormone which stimulates her breast milk prior to birth transfers through placenta to baby - temporary; never massage or squeeze
Abdomen	- dome-shaped abdomen - abdominal respirations - soft to palpation - well formed umbilical cord - cord dry at base (remnants up to 2 -3 weeks of age) - liver palpable 2 - 3 cm below right costal margin - bilaterally equal femoral pulses - bowel sounds present - voided within 24 hours of birth - meconium within 24 - 48 hours of birth	- bowel sounds absent - peristaltic waves visible - abdominal distention - palpable masses - scaphoid-shaped abdomen - omphalocele - base of cord with redness or drainage	- teach cord care and warning signs that would suggest the presence of infection. During the first few weeks keep the umbilicus clean, fold diapers so cord doesn't become soiled.( Do not have to use alcohol) Full baths are ok.	- refer to medical care provider if cord abnormality observed (i.e. discharge, odor, redness, swelling)
Female Genitalia	- edematous labia and clitoris - labia majora are larger and surrounding labia minora - vernix between labia - hymenal tag is a common neonatal variation that usually disappears in a few weeks -during the 1st week of life the baby may have vaginal discharge composed of thick whitish mucus which can be tinged with blood	-continuing vaginal discharge - labia fused - fecal discharge from vaginal opening - imperforate hymen - ambiguous genitalia - widely separated labia	- teach about vaginal discharge, blood tinged & cause by maternal hormone; resolves by the 1st week of life - cleansing of all perineal folds should be done gently when bathing and at diaper change
Male Genitalia	-2 testes felt in scrotum; hydrocele, a collection of fluid surrounding the scrotum, is common in newborns -genitalia may have edema due to maternal hormones which should decrease in a few days - uncircumcised foreskin normally adherent; cannot be completely retracted until 5 years and sometimes not until puberty (American Academy of Pediatrics)	-undescended testes - circumcision infection: purulent discharge, redness/induration, odor - hypospadius - epispadius - scrotum smooth - ambiguous genitalia	-hydrocele is common and usually resolves by 6 months of age -give guidance regarding bathing/cleansing the non-circumcised penis. - teach retraction of foreskin is not recommended - circumcision: teach possible signs of infection & answer questions -yellowish covering of glans while healing is normal -instruct parents to apply vaseline or bacitracin and guaze on the penis w/ each diaper change for at least 24-48 hrs to keep the diaper from adhering to the site. Bacitracin or vaseline only until it heals, 7-10 days old
Back & Rectum	- intact spine without masses or openings - trunk incurvature reflex - patent anal opening - "wink reflex" present	- limitation of movement - fusion of vertebrae - spina bifida - tuft of hair - imperforate anus - anal fissures - pilonidal cyst
Extremities	- maintains posture of flexion - equal and bilateral movement and tone - full range of motion all joints - ten fingers and ten toes - legs appear bowed - feet appear flat - palmar creases present - sole creases present - negative hip click - grasp reflex present (lessens at 3 – 4 months)	- unequal tone - asymmetrical movement of extremities - polydactyly - syndactyly - unequal leg length - asymmetrical skin creases posterior thigh - dislocation of hip - Simean crease - persistent cyanosis of nail beds - marked metatarus varus	- explain that shoes not needed other than for warmth - reassure that infant's legs often remain bowed until about 18 months
Neuromuscular	- maintains position of flexion - when prone, turns head side to side - holds head and back in horizontal plane when held prone - ability to hold head momentarily erect	- hypotonia - quivering - limp extremities or straightening of extremities - clonic jerking - paralysis
Reflexes	Root reflex This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding. Suck reflex Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or hands. Moro reflex The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his/her head, extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him/her and begin this reflex. This reflex lasts about five to six months. Tonic neck reflex When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts about six to seven months. Grasp reflex Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. The grasp reflex lasts only a couple of months and is stronger in premature babies. Babinski reflex When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age. Step reflex This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solid surface.
Breastfeeding	Refer to Breast Feeding Guide
Bottle Feeding (Forumula)	2 – 4 ounces every 2 – 4 hours.		Assess if parents/caregives have enough formula & bottles/nipples on hand. - key teaching points: Be sure to carefully follow directions on the label when preparing formula. Bottles left out of the refrigerator longer than 1 hour and any formula left in the bottle that a baby doesn't finish should be discarded. Prepared bottles of formula should be stored in the refrigerator for no longer than 24 hours and should be carefully warmed just before feeding. A bottle of formula (or breast milk) should not be warmed in a microwave. The bottle can heat unevenly and leave "hot spots" that can burn a baby's mouth.

References

CDC. (2007). Project Title: National Burden of antimicrobial resistant neonatal sepsis (Antimicrobial Resistance Interagency Task Force Action items # 3 - 7). Atlanta, Georgia: Centers for Disease Control.

Guide to postpartum and newborn physical assessment, anticipatory guidance and health teaching. (2005). Division of Community Public Health Maternal Child Health Program Department of Health.

Homeier, B. (2005). Formula feedings faq's. Retrieved October 28, 2008, from Kids Health for Parents Web site: http://kidshealth.org/parent/pregnancy_newborn/formulafeed/formulafeed_starting.html

Hotelling, B (2004).Newborn capabilities: Parent teaching is necessary. The Journal of Perinatal Education. 13, 43 - 49.

Jarvis, C. (2003). Physical examination & health assessment. St. Louis, Missouri: Elsevier.

Olds, S., London, M., Ladewig, P. & Davidson, M. (2004). Maternal-Newborn Nursing and Women’s Health Care. (7th ed.). Pearson-Prentice Hall. Chapter 34.

Ohio State University. (2005). Neonatal sepsis (Power Point) Kirstine Crowley, M.D.