Newborn Assessment Study Guide

MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY Maternal Infant Nursing 316

Upon completion of this study guide, the student will be able to:

1. Identify the assessment criteria for each component of the physical assessment of the newborn. 2. Discuss the significance of the assessment findings for a normal newborn. 3. Identify and distinguish between variations in the six (6) physical characteristics and six (6) neuromuscular characteristics used to determine gestational age of the neonate using the Ballard Gestational Age Assessment Tool. 4. Identify a minimum of eight (8) reflexes exhibited by the newborn. 5. Correctly identify the infant as appropriate, small, or large for gestational age based on the scoring tool findings (Ballard Assessment).

Directions:

1. View the videotapes "Physical Assessment of the Newborn" and "Gestational Age Assessment" on the library’s 2nd floor reserve Media Resource Center under Lynn Kennell’s name. [DVD 1883 2 parts]

2. Use the attached assessment guide to make notes on both the "Quiet Exam" and the "Head-to-Toe Sequence" while viewing the "Physical Assessment" tape. Use the Ballard Gestational Assessment and Growth Chart in your text and complete the worksheet while viewing the "Gestational Age Assessment" tape.

3. Refer to your texts for further clarification and reference: Hockenberry et al: Newborn Physical Assessment Davidson, et al: Chapter 28- Nursing Assessment of the Newborn: pp. 670-705

Evaluation:

1. An online objective quiz on Blackboard will be taken by each student on a date to be announced. This test will be worth 25 points of your total CTE Points. 2. During the maternity rotation, you will complete a newborn physical assessment and gestational assessment and include it with the Patient-Client Assessment Form when you are assigned to the nursery. Terminology for Physical Assessment of the Newborn

Acrocyanosis - A bluish discoloration of the hands and feet due to sluggish peripheral circulation.

Barlow's maneuver - A procedure to rule out congenital hip instability; flexion of the legs, abduction of the hips to approximately 90 degrees, then downward pressure is exerted while adducting the thighs. A positive sign is palpable dislocation during the maneuver.

Caput succedaneum - A collection of fluid in the soft tissues of the scalp that may override the suture lines. Caused by pressure on the presenting part of the head against the cervix during labor.

Cephalohematoma - A collection of blood between the periosteum and the cranial bone (usually the parietal bone) appearing as unilateral or bilateral and limited to the suture lines of the affected bone(s). A result of the extravasation of ruptured blood vessels from the pressure of birth.

Diastasis recti - Gap between abdominal recti muscles.

Epstein pearls - Small, white, round epithelial cysts on the hard palate and along the gum margins.

Erythema neonatorum toxicum - "Newborn rash" or flea bite rash. A generalized rash characterized by red, elevated papules appearing around 24-48 hours of age. Resolves without treatment.

Fontanelle - "Soft spot". An area of fibrous tissue over the juncture of the cranial bones.

Lanugo - Fine downy hair of varying distribution covering the body with exception of the palms of the hands and soles of the feet.

Milia - White, pinpoint papules on the chin and/or nose resulting from unopened sebaceous glands.

Molding - Shaping of the head caused by overriding of the cranial bones to facilitate movement through the birth canal.

Mongolian spots - "Oriental patches". An area of bluish-black pigmenta-tion over the buttocks and the lower back, commonly seen in non-Caucasian races.

Mottling - Discoloration of the skin in irregular areas resembling a lace-like pattern.

Occipital-frontal circumference (OFC) - The greatest circumference of the head, i.e., over the supraorbital ridges and the occipital prominence.

Ortolani's maneuver - A procedure to rule out congenital hip dislocation: flexion of the legs, abduction of the hips to approximately 90 degrees, then forward pressure from behind the greater trochanter while the thigh is abducted. A positive finding is a "click", which is palpable as the dislocation is reduced.

Pseudomenstruation - White or blood-tinged mucous discharge from the vaginal secondary to the withdrawal of maternal hormones.

Rugae - Folds of tissue over the scrotum that allow for expansion of the tissue.

Subconjunctival hemorrhage - An area of bleeding on the sclera due to changes in vascular tension during birth.

Telangiectatic nevi - "Stork bites" or capillary hemangiomas. A flat area of capillary dilatation appearing as small clusters of pink-red spots on the nose, nape of the neck, lower occipital bone, and eyelids, which blanch easily.

Vernix caseosa - A white cheese-like substance covering the body, particularly noticeable in the creases of the skin. MENNONITE COLLEGE OF NURSING at ILLINOIS STATE UNIVERSITY Parent Child Nursing - 323

Reflexes in the Neonate (See text for more reflexes)

REFLEX STIMULUS RESPONSE SEEN NOT SEEN

Moro Infant lying on back, Arms extended, head Birth 4 months slightly raised head thrown back, fingers fat suddenly released; out; arms brought back infant lowered abruptly to center with hands clenched; legs extended Rooting Lightly stroke cheek Head turns toward Birth 4 months with finger stimulus Sucking Insert finger into infant's Rhythmic sucking Birth 7 months mouth Startle Loud noise Similar to Moro Birth 4 months response Palmar (grasp) Touch palm with finger Grasp object, holds Birth 6 months or object tightly Tonic neck Head turned to one side Arm and leg extend on 2 months 6 months (fencing) while infant lies on back the side infant faces. Opposite arm and leg extend. Blinking Light flash Eyelids close Birth ----- Stepping Infant supported in an Rhythmic stepping Birth 6 weeks upright position with movements feet touching flat surface. Babinski Stroke the sole of foot Toes fan out Birth 12 mo. from heel to toe laterally *This assessment guide follows the videotape. The systematic approach makes key assessments while the baby is quiet, then moves into a head-to-toe sequence. Reflexes are integrated with the appropriate systems.

QUIET EXAM

Component Common Variations Posture Hands clenched, Flexion, adduction of extremities Front breech may have extended legs and abducted thighs Assessment CriteriaPosture Temperature Normal Findings Vital Signs: Axillary: 36.5 - 37oC (97.7 - 98.6oF)

Pulse 120-160 beats/minute Varies with body temperature, period of reactivity, physical activity

Quality

Rhythm

Heart Sounds 120-160 beats/minute

Strong

Regular

PMI: 4th-5th intercostal space left of midclavicular line

Listen over entire precardium Varies with body temperature, period of reactivity, physical activity During sleep, as low as 100bpm; with crying, as high as 180bpm

Often visible Apex of heart is at PMI in neonate

Transient murmurs secondary to incomplete closure of ductus arteriosus or foramen ovale Respirations Rate

Quality Rhythm

Breath Sounds 30-60 breaths/minute

Relaxed, synchronized movement of the chest and abdomen

Irregular—Assess for full minute

Bronchovesicular sounds with inspiration, expiration equal in duration Varies with body temperature, period of reactivity, physical activity

Bowel Sounds

Sibilant and sonorous wheezes in immediate post delivery period Blood Pressure

Systolic: 54-92 in males Diastolic: 38-72 in males

Systolic: 46-84 in females Diastolic: 38-72 in females

Location Present in all 4 quadrants Bowel sounds may be absent during first period of reactivity.