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Outcomes Newborn Assessment • Understand newborn history • Discuss APGAR scoring Dr. Susan Ward PhD, RN, LCCE • Discuss newborn vital signs, weight and Lee Ann Caracciolo RN measurement • Examine newborn medications • Explore newborn assessment • Practice newborn assessment test questions

History History Antepartum/OB Intrapartum • Para/gravida • Maternal age • Prenatal care • Prenatal care • Spontaneous/induction • Previous preterm • Pre-existing medical births/complications • Medications conditions such as • Medications - Rx, • Membranes ruptured? infertility, chronic illicit, over-the- • Meconium stained? counter, tobacco or hypertension… • alcohol use • High risk factors such Type of delivery • EDC as GDM, clotting or • Apgar scores

seizure disorders • Antenatal testing

Apgar Scoring (not predictive of neonatal mortality or morbidity) • Performed at 1 and 5 minutes of age • If the Apgar score is less than 7 at 5 minutes of age, the Neonatal Resuscitation Program guidelines state that the assessment should be repeated every 5 minutes for up to 20 minutes • Reflects status of infant and response to resuscitation

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Newborn Vital Signs (37to 41 weeks) Other assessment questions Vital Signs • Temperature - is the baby overwrapped, just • Temperature finished nursing or was he snuggling with • Normal axillary is 97.7-99.3 degrees F • Heart Rate mom? • Normal range 100-160 beats per • HR- is the baby awake? HR can decrease to 70 minute bpm while sleeping. Does the HR increase • Respiratory Rate with stimulation? • Normal range 30-60 beats per minute • RR - what is the baby’s color? and non-labored

*Count HR and RR for one full minute

Weight and Measurement Medications • Use a growth chart to determine SGA, AGA, LGA Vitamin K (phytonadione)

• Weight (average 3405 gm or 7 lbs 8 oz) • Every newborn receives a single parenteral dose (IM) of natural Vitamin K1 (phytonadione) 0.5 to 1 mg • Less than 2748 grams (6 lbs) small for gestational age or preterm, greater than 4050 grams (9 lbs) large for gestational • Prophylaxis and treatment of Vitamin K deficiency age or infants of diabetic mothers bleeding (VKDB) • Coagulation factors (II, VII, IX, & X) formed in the • Chest circumference • Measure at level of nipples after exhalation liver • 30-35 cm (12-14 inches) • Requires Vitamin K for final synthesizes. • Sterile intestinal flora does not allow for Vitamin K • Head circumference • Measure just above eyebrows and around to occipital synthesis prominence in back of skull • Administer shortly after birth • 32 to 37 cm (12.5 to 14.5 inches) • Oral administration has not shown to be as effective • Length for prevention of late hemorrhagic disease • Measure top to head to heel • 48 to 52 cm (18 to 22 inches)

Hepatitis B Vaccination Eye Prophylaxis • Hepatitis B is a contagious liver disease caused by the hepatitis B virus • Erythromycin 0.5% ointment is the most effective prophylaxis medication for vaginal and cesarean • All medical stable babies receive the first vaccine of hepatitis B deliveries against Gonococcal Ophthlamia vaccine before they leave the hospital Neonatorum and Chlamydia

• The vaccine acts as a protectant, reducing the newborn’s risk of • Administration of eye prophylaxis is required in all acquiring the disease from the mother or family members who states may not know they are infected with Hepatitis B Virus

• The administration of the ointment may be delayed • B Vaccine (Engerix-B, Recombivax HB) - the 1st dose of 10 mcg is until after initial breastfeeding in the delivery room given IM in vastus lateralis

• The eye ointment should reach all parts of the • Hepatitis B Immuno-globulin (HBIG) - 0.5ml given IM if the conjunctival sac. After one minute the excess mother’s HBsAg status is positive or unknown, within 12 hours of medication can be wiped away with a sterile cotton birth swab or gauze AAP & ACOG (2012, p. 295)

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Techniques of Physical Assessment Newborn Assessment Assessment Skills Basic Principles • Observation • First hours of life • Auscultation • Subtle signs/symptom(s) – one • Palpation sign or a combination of • Percussion signs • Translumination • Review history for (scrotal sac) potential clues • Quiet environment • Calm and warm infant

Physical Assessment Skin Assessment • Head to toe assessment – Count umbilical vessels Skin Color and Variations • Two arteries, one vein • Pink, warm and dry are the standard indicators that • Report a two vessel cord verify a newborn’s overall health status – Apgar scoring – Vital signs • All healthy newborns have a pink tinge to their skin – Weight and measurements – Medications • The pigment, melanin, is passed on to a newborn by – Skin his/her parents and determines skin tone, which can – Head and neck darken overtime based on genetic disposition – Respiratory system – Cardiovascular system • Ruddy skin color is due to the increased red blood cell – Abdomen concentration in the blood vessels and limited – Musculoskeletal system subcutaneous fat deposits (plethora) – Genitourinary system – Neurologic system

Acrocyanosis (bluish color of hands and feet and might be present in first 24 hours of life) Skin Assessments and Variations • Assess for meconium staining • Inspect the newborn’s back for a closed vertebral column and for any abnormalities (closed” spina bifida or called Spina Bifida Occulta - causes no problems) • Dimpling Circumoral Cyanosis (cyanosis around the mouth) • Tuft of hair • Masses • Assess turgor (hydration status) • Skin should be elastic and should return rapidly to its original shape

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Vernix Caseosa Lanugo

• Fine “downy” hair • A protective layer or covering (in utero it protects the • Part of gestational age assessment newborn that is surrounded by amniotic fluid) • At term, Lanugo is only present on shoulders, forehead and pinna of • Cheese-like, thick, whitish, substance fused to epidermis ears • Vernix Caseosa is visible in the skin folds, creases, • Lanugo in Postmature newborns axillary and genital areas is absent • Lanugo in Premature newborns • The actual amount found is effected by gestational age is long and thick on the back • Note the color – green (meconium stained), yellow (Rh and/or shoulders blood incompatibility), foul smell may indicate intrauterine infection that could be passed on to the newborn

Mottling Skin Color and Variations • Cutis Marmorata or Skin Mottling is a “lacy pattern” on the skin and occurs as a result of general circulation Jaundice (physiological or Icterus fluctuations. It can last several hours to several weeks. Neonatorum) results from the accumulation Mottling may also be related to chilling, prolonged apnea, sepsis or hypothyroidism of bile pigments and associated with an • Capillary refill is > 3 seconds is abnormal – provides excessive amount of bilirubin in the blood. Is information about the infant’s cardiac perfusion worsened by ecchymosis – forcep marks, severe caput, cephalohematomas, bruising due to trauma. Seen in 30-50% of all normal term newborns

Skin Color and Variations Skin Color and Variations • Hyperbilirubinemia • Administer phototherapy (the level of bilirubin determines if – Occurs within the first 24 hours of life the newborn is placed under single, double or triple – The Total Serum Bilirubin (TSB) increases by 0.5 mg/dL per phototherapy). Side effects of phototherapy are loose hour or 5mg/dL per day watery stools, diaper rash and dehydration – The diagnosis is made when the TSB concentrations climb ≥ • Fiber optic systems (Bili Blanket) can also deliver 12.9 mg/dL in a term infant and ≥ 15/mg/dL in a preterm phototherapy in a blanket form placed under or around the infant newborn – Visual observation is first noticed in the head and gradually • During phototherapy cover the newborn’s eyes and genital progresses to the thorax, abdomen and extremities area to prevent retinal and tissue damage. Remove the mask during feedings and shut off the lights – Use the Transcutaneous bilirubinometry (TcB) which is non invasive way to get a more accurate then visual reading of • Monitor the newborn’s temperature closely for hypothermia the infant’s bilirubin level • Excess bilirubin is excreted through the stools

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Mongolian Spot Harelequin Sign (Congenital Dermal Melanocytosis)

Difference in color of half of the face or body (Harlequin’s sign) generally related to immature hypothalamic center The most common pigmented lesion in newborns

Flushing occurs on dependent side (this Mistaken for a bruise due to newborn was placed on right side before gray/green color the current supine position) Location is the buttocks, flanks, or shoulders

May fade over time

Milia - raised white Epstein Pearls - Forcep Mark spots on the face and whitish-yellow cysts nose that form on the gums • Pressure marks are typically red or and roof of the mouth bruised areas from the use of forcep on the face, scalp, and/or cheeks • Examine the infant thoroughly or note other complications such as skull fracture, fractured clavicle, facial palsy

Bohn’s Nodules - grayish white lesions in this newborn's mouth that resolve spontaneously

Accessory Nipple(s) Erythema Toxicum Neonatorum • Accessory or supernumerary nipple(s) can be single or Newborn rash (cause unknown) –a multiple, flat, tan or brown spots along the “milk line” below and medial to the true nipple(s) pale yellow colored papule or pustules that vary in size from 1 to 3 • Often darken at puberty millimeters • Diagnosed when dimpling occurs when adjacent skin is stretched away from the nipple(s) Most commonly found on the trunk • May also be associated with glandular tissue and diaper area and is widespread • A whitish secretion from the nipples may also be noted. but does not appear on the palms of The infant’s breast should not be massaged or squeezed the hands or the soles of the feet because this practice may cause a breast abscess

May appear quickly and may last up to 3 months of life – no treatment is necessary

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Cafe`au Lait Spot Common or Simple Nevus (means “coffee with milk”) “Birth Mark” • Tan or brown in color • The color of a nevus depends upon the amount of melanin or skin pigment • Oval-shaped macule (flat) • A dark brown or black macule commonly seen • If less then 3 cm or less than 3-5 in number, on the lower back or buttocks there is no pathologic significance • Nevi may be associated with hair. Flat Nevi without hair rarely need removal • The presence of 6 or more spots >.5 cm in length • If the Nevi or tufts of hair are found in sacral may indicate cutaneous Neurofibromatosis (an area– it is associated with Spina Bifida autosomal dominant disorder in which tumors of Occulta various sizes form on peripheral nerves) • Some Nevi can have malignant changes and should be observed closely for changes in size or shape

Capillary Hemangiomata or Capillary Hemangioma Port Wine Stain Nervus Simplex or Telangiectatic Nevi • Common in newborns – appear as pink or red spots. Common in light complexioned newborns and are more noticeable during periods of crying • Generally found on nape of neck, lower occipital area, eyelids, above upper lip Also known as “Nevus Flammeus” (flat, red purplish color) • Blanche with pressure • Does not blanche with pressure • Fade spontaneously by end of first 2 years – no treatment • Soft and compressible with poorly defined borders necessary • Will not grow or spontaneously disappear but may get darker and thicker with time Link to photo of • If convulsions or other neuralogic problems Capillary accompany the Nevus Flammeus, it is suggestive Hemangioma of Sturge-Weber syndrome with involvement of the https://www.medicinenet.com/image- th 5 cranial nerve collection/lymphedema_picture/picture.htm

Infantile Hemangioma

Also called Nevus Vasculosus

Former name was “Strawberry Mark” Newborn Assessment

Bright red, raised tumor typically on the head, neck, trunk, or Head, Neck, Face, Eyes, Ears, extremities Nose and Mouth

The lesion may grow quickly for about six month then slowly begin to regress, it may take several years to completely go away

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Head Craniotabes (softening or thinning of the skull) • The head may appear egg shaped due to molding that occurs with a vaginal delivery – this condition usually resolves within a few days to • Usually this is due to external pressure from weeks of life prolonged vertex engagement or pressure of the • Inspect and palpate the infant’s skull and identify fetal head on the uterine fundus with a breech bones, sutures, fontanels for size and symmetry presentation of head. Is there presence of molding, caput, • Palpate skull for softening of cranial bones and/or bruising? • When palpating the area will collapse and then • Palpate suture lines recoil, the sensation is similar to pressing on a • Palpate cranial bones ping pong ball

• This condition resolves in a few weeks if this is due to external pressure and not a metabolic or underlying disease process

Fontanelles Molding Vaginal Palpate the Fontanelles Delivery • Assess with newborn sitting and not crying • The fontanelles may swell with crying or passage of stool • Depressed anterior fontanelle may indicate dehydration • Overlapping of cranial bones during labor • Bulging fontanelle may signify increased intracranial and delivery pressure or infection • Type of delivery will impact shape and the • Fontanelles may be smaller immediately after birth than amount of molding will depend on much several days later pressure was placed on the head • Posterior fontanelle • Head circumference usually returns to • Smaller and triangular normal within 2 to 3 days after birth and • Closes within 8 to 12 weeks the suture lines become more palpable • Anterior fontanelle Breach • A baby born by cesarean or breech will • Diamond shaped head usually have a more symmetrical shaped • Closes within 18 months head

Cephalohematoma Caput Succedaneum • Bleeding into space between the bone and • Usually due a difficult labor or use of a vacuum periosteum extractor (vacuum extractor may cause a circular • Appears on first and second days of life shape and take longer to resolve) • May be unilateral or bilateral • The fluid is reabsorbed in about 12 hours to a few days after delivery • Doesn’t cross the suture lines • There is a slow venous return which may cause • Common in a vertex birth increase in tissue fluids, edema and sometimes bleeding under the periosteum • The scalp may feel loose and somewhat edematous

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Subgaleal Hemorrhage Neck Potentially this condition Assess: SubgalealSkin hematoma is the most serious effect Periosteum • Symmetry from birth trauma but it is Bone • Is there full range of motion? the least common • Appearance – is it normal or does the neck have a Signs and Symptoms short and thick appearance ? • Generalized scalp • Torticollis edema – Contraction of neck muscle pulling head to one • Usually with side ecchymosis – May be congenital or occur during the birth • Bilateral or unilateral process periorbital edema Subgaleal Hematoma formation – Results from injury to sternocleidomastoid muscle • Ballotable fluid • Cystic Hygroma crosses suture lines – Cyst usually on lateral neck • Firm to fluctuant – If it is large it can deviate the trachea and cause tension respiratory distress

Face Eyes • Assess eyes for symmetry in size and shape • Eyes and/or eyelids may be edematous after birth • Eye color • Observe for symmetry, bruising and/or petechiae • Usually slate gray, brown, or dark blue • Observe for congenital syndromes • Eye color becomes permanent after 6 months of age • Assess when the newborn is crying Sclera • If it was a forceps delivery, assess for injury: • Usually bluish – white in color • Facial nerve palsy (7th cranial nerve) • May have Subconjunctival Hemorrhages which • Drooping mouth appearance usually resolve in a week • Decreased movement on affected side of • If the sclera is yellow further assess for face hyperbilirubinemia

Eyes Eyes

• Are there tears present? Tears are usually absent until the • Strabismus duct becomes fully patent at 4 to 6 months of age • Cross eyed appearance often seen in • Prominent epicanthal folds are normal in Asian infants but newborns may suggest Down Syndrome • During the opthalmoscopic exam assess: • Nystagmus • Red reflex, is it present? • Rapid, searching movement of the eye • Red reflex, is it absent? • Usually disappears by 4 months of age • Suggests congenital glaucoma or cataracts • Pale red reflexes are a normal variation in dark- • Newborns can see objects clearly at 8 to 10 skinned newborns inches in front of them • Newborns are nearsighted at birth • Are the corneas and lens intact? • Respond to bright or primary colors • Respond to high contrast such as black and white

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Abnormal Eye Assessment Persistent purulent discharge Ears • Opthalmia Neonatorum (conjunctivitis, neonatal eye Assess: infection) • Chlamydial Conjunctivitis • Ear position – draw an imaginary line from • Blocked tear duct inner to outer canthus of eye toward ear • Chemical Conjunctivitis (getting smoke, liquids, fumes, • If insertion falls below line, it is low-set or chemicals in the eye) • Genetic syndromes Blue sclera • There may be temporary asymmetry from • Osteogenesis Imperfecta intrauterine position Sclera visible above iris (sunset eyes) • Hydrocephalus

Pupils unequal, fixed, and nonreactive • Neurologic insult

Keyhole shaped pupil (coloboma - is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc) • Syndrome associated anomalies Breastfeeding Atlas 3rd ed.

EARS Ears Normal vs. Low Set Benign variations shown are: • Initial embryonic ear development by mandible with A. Pre-auricular sinus upward progression during fetal development A B B. Prominent (protruding) • Low set placement of ears seen with ears • genetic syndromes (i.e., Trisomy 13, 18, 21) C. Darwin’s Tubercle • abnormal development of internal organs – D. Incomplete Helix especially Potters’s Syndrome (renal agenesis) C D development (seen mostly with premature infants– final ear cartilage development in last 4 weeks of gestation)

Nose Abnormal Nose Assessment Findings Pathology • Symmetric and midline • Flat nasal bridge • May see nasal stuffiness and thin, white mucus • Down syndrome immediately after birth • Pink when crying, chest retractions and • Sneezing is normal • Choanal atresia cyanosis at rest, • Assess for bilateral nasal patency • Neonatal drug difficulty feedings • By alternately obstructing one nares then the other withdrawal • Stuffy nose and thin, • If necessary, insert 5 French catheter to check • Congenital syphilis watery discharge patency • Persistent “sniffles” with profuse mucopurulent or bloody discharge

(Simpson & Creehan, 2014 p 606 Table 19-5)

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Mouth Mouth (Tongue)

• Symmetrical Ankyloglossia or “Tongue Tie” - restricts • Sucking blisters may be present the tongue's range of motion • The lingual frenum attaches superior to rd • Mucous membrane pink- assess for Breastfeeding Atlas 3 ed. normal placement– possibly to tip of tongue cyanosis • Only treated if problems with feeding or • Increased amount of mucus during first speech two days of life

Breastfeeding Atlas 3rd ed. Macroglossia or enlarged tongue • Seen with metabolic problems (i.e., Hypothryoidism) • Seen with genetic defects (i.e., Trisomy 21, gargoylism or dwarfism)

Mouth Abnormal Mouth Findings Microganthia (condition in which the jaw is • Weak, uncoordinated suck/swallow undersized) • Prematurity • Seen in Pierre Robin Sequence (a set of • Neurological disorder abnormalities affecting the head and face) • Maternal analgesia during labor • Hypoplasia of the mandible Excessive drooling and salivating Natal teeth • Unable to pass NG tube • One or two natal teeth • Esophageal Atresia (the upper esophagus ends and does • Usually are loose not connect with the lower esophagus and stomach) • Usually removed so newborn cannot aspirate • Thin upper lip, flat philtrum (cleft in the middle area of the Uvula upper lip) • Should be midline • Bifid uvula (divided by a deep cleft or notch into • Fetal alcohol syndrome two parts)

Breastfeeding Atlas 3rd ed.

Abnormal Mouth Findings Newborn Assessment • Dry mucous membranes • Dehydration Respiratory • Cyanotic mucous membranes • Central cyanosis • Frantic sucking • Infant of drug-addicted mother • Patches of white on tongue and mucous membrane • Candida Albicans (Thrush)

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Fetal Lung Fluid Fetal Lung Fluid • After delivery, in preparation for extrauterine • Typically by 34-36 weeks of gestation the fetus life, the infant expands his/her lungs that has produced enough surfactant to maintain stimulates the release of surfactant which alveolar stability helps decrease the surface tension within the • The absorption of the fetal lung fluid is speed up alveoli during the labor and delivery process, and • The first breath of air by the infant causes fetal during a vaginal delivery about 1/3 of the fluid is expelled due to the thoracic squeezed from circulation to convert to neonatal circulation coming out the birth canal • When the infant draws in air, the lungs expand, pulmonary vascular resistance declines which then causes pulmonary vasodilation and an increase in blood flow to the lungs

First Breath Four factors will influence the initiation of the infant’s first breath First Breath (Continued)

1. Sensory - There are several tactile, visual, 3. Mechanical - The fluid in the lungs is and auditory stimuli for the infant once the removed and replaced with air, which is newborn enters the outside world which the primary mechanical factor in the help with the initiation of the first breath initiation of respirations

2. Chemical - The three chemical factors are- hypercarbia, acidosis, and hypoxia. 4. Thermal - There is a radical drop in These three chemical factors are brought temperature going from in utero to the on through the stress of labor and delivery outside world, sensors in the skin respond to and stimulate the respiratory center in the the temperature change and send signals to brain to initiate breathing the respiratory system in the brain to initiate respirations

Respiratory Assessment • Average respiratory rate is 30 to 60 bpm • Respirations are typically shallow and irregular • Periodic breathing is a pause in respiratory movements that lasts for up to 20 seconds alternating with breathing. This can be more common in preterm infants but can occur in term infants • It is not common to have skin color changes or heart rate changes • Chest movement should be symmetrical • Diaphragmatic breathing is normal • Observe color – cyanosis

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Respiratory Assessment Abnormal Respiratory Findings Lung sounds Tachypnea • Louder and courser in newborns because there is less • Respiratory rate greater than 60 bpm (no oral feedings) subcutaneous tissue • Fine crackles (rales) may be heard in the first few hours Respiratory distress after birth and has also been associated with Acute • Retractions, flaring, grunting Respiratory Distress Syndrome and Bronchopulmonary • See-saw movement of chest and abdomen Dysplasia Newborns have periodic breathing patterns due to immaturity of Retractions respiratory and central nervous systems • Drawing back of the chest wall with inspiration and occur when • It is not unusual to see brief pauses in respiratory effort the accessory muscles are used for breathing. In the chest, common sites for retractions include suprasternal, supraclavicular, Apnea intercostal, subcostal, and substernal • Pauses in respirations lasting 20 seconds or longer • If associated with color change or bradycardia, report to the  Assess the infant’s respiratory status including increasing respiratory health care provider immediately rate and decreasing oxygenation

Newborn Assessment

Clavicles • Should be smooth and straight Newborn Assessment • Palpate for fracture • Crepitus (grating sound) may be felt Neonatal

Circulation Breasts • Hypertrophy of breast tissue may be present by second or third day of life • May or may not have a milky secretion due to maternal hormones (do not massage breasts) • Breast engorgement usually subsides in 1 to 2 weeks • Supernumerary nipples may be present but benign

Fetal Circulation

Fetal Circulation https://www.youtube.com/watch?v=8WX0POOZhvE See shunt closure • Oxygenated blood from inferior vena cava enters right atrium, through to left atrium then left ventricle and on to ascending aorta where it is directed to fetal heart and brain • Superior vena cava drains deoxygenated blood from head and upper extremities into right atrium where it mixes with oxygenated blood from the placenta • Blood enters right ventricle and pulmonary artery where the resistance in the pulmonary vessels causes 60% of this blood to be shunted across the ductus arteriosis and into the descending aorta • The mixture of this oxygenated and deoxygenated blood continues through the descending aorta oxygenating the lower half of the fetal body and eventually draining back into the placenta through the 2 umbilical arteries…the remaining 40% of the blood coming from the right ventricle perfuses lung tissue to meet metabolic needs

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Abdomen • Bowel sounds are audible at 15 minutes after birth, but Newborn Assessment are faint/quiet until feeding begins

Abdomen • Normally rounded and symmetric (measure circumference)

• Protuberant and soft

• Easy movement up and down associated with respirations

• Chest and abdomen should rise at same time • If asynchronous (see-sawing) it can indicate respiratory distress

• After 36 weeks gestational age, abdominal circumference is greater than head circumference

Abnormal Abdominal Assessment Abnormal Abdominal Assessment Diastasis Recti (separation of the abdominorectus muscle) - is not uncommon • Prune Belly • Can be seen as a midline, elevated ridge from below the • Congenital absence of abdominal musculature sternum to the umbilicus when newborn is crying • Associated with severe renal and UTI abnormalities • Due to newborn’s weak abdominal muscles • Resolves without intervention • Markedly distended abdomen may indicate bowel obstruction • A sunken or scaphoid abdomen May indicate a diaphragmatic hernia or dehydration • Umbilical Hernia • Normal preterm infant • Common finding in 30% of term African American May appear distended due to lack of muscle tone infants • Also seen in low birth weight males • Term infant • Close spontaneously by 2 years of age May have decreased muscle tone due to maternal medications received in labor

Umbilical Cord Omphalitis (infection of the cord)

• Shiny, pearly white, and gelatinous • Redness encircling the cord and extending into • A yellow or green cord may indicate meconium the abdomen staining occurred 6 to 12 hours prior to delivery • Must be treated promptly • Two arteries, one vein • May indicate a small Omphalocele (a birth • Wharton’s jelly protects vessels defect in which an infant's intestine or other • Indicator of infant’s nutritional status abdominal organs are outside of the body. The • Any unusual bulging in cord is evaluated intestines are covered by a thin layer of tissue • Usually falls off in 10 to 14 days and can be easily seen)

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Newborn Assessment Newborn Assessment Perianal Area Musculoskeletal System • Inspect for presence and placement of anus

• Patency established by passage of meconium • Usually within 24 – 48 hours of birth • If anus is absent it suggests Anal Atresia • Passage of small stool suggests stenosis

Musculoskeletal Musculoskeletal • Position • Flexion of both upper and lower extremities • Look for extra or missing digits and webbing • Symmetrical • Syndactyly • Asymmetrical • Congenital webbing of fingers and toes • Possible injury related to birth trauma • May be familial • Presence of abnormal movements • Polydactyly • Count fingers and toes • Extra digits • Palpate clavicles for fractures • May feel crepitus or a lump • Assess for normal muscle tone

Brachial Plexus Injury Brachial Plexus Injury • Associated Factors/Risks • Injury to Brachial Nerve Plexus • Erb’s palsy • Shoulder dystocia has also occurred in • Complete or partial paralysis of the shoulder newborns delivered by cesarean without labor muscles as a result of C5 and C6 neurologic injury • Positioning in utero • Grasp reflex intact but Moro reflex is absent on affected side • Large babies • Klumpke’s • Breech position • Involves C8 and T1 injury • Complete or partial paralysis of forearm and hand muscles • Complete paralysis of arm • Treatment • Aimed at preventing contractures • Usually resolves in 3-6 months

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Phrenic Nerve Paralysis Extremities • Controls diaphragm Polydactyly and Syndactyly • Usually associated with Brachial injury • Polydactyly or Super-numerary digits • Usually unilateral • Occur on hands or feet • Position on the affected side because otherwise • Most common upper extremity anomaly respiratory effort is impaired • Skin tag (ligation) verses complete appendage • Pneumonia often occurs (surgery) • Syndactyly - is abnormal fusion of the digits or Avulsion (complete disconnection of nerves) “webbing” • Permanent damage • Usually found in 3rd and 4th fingers and/or 2nd and 3rd toes • Graft surgery may be an option • Requires surgical repair

Developmental Dysplasia of the Hip Performing the Barlow Test (steps 2 and 3) and Ortolani’s (DDH) Maneuver (step 4) • Risk factors: • Family history 1. Place the infant supine on a flat surface • Oligohydramnios • Breech presentation 2. Place your thumbs on the infant’s inner thigh and your fingers • Foot deformities on the outside of the greater trochanters of the hips

• Primiparity

• Female sex 3. Flex the infant’s knees and move the legs inward until your • Multiple pregnancy fingers touch • Assess • Asymmetric gluteal folds

• Ortolani maneuver • A palpable clunk is noted when abducting the hip 4. Use genital but firm pressure, rotate the hips outward so the • knees touch the surface Barlow maneuver • Clunk palpated when thigh adducted *No clicking or crepitus should be heard

Extremities Extremities HIP and Sacral Assessment Hip and Sacral Assessment Spina Bifida Occulta • Pilonidal Dimple • An abnormal hair growth, lipoma, capillary • A pilonidal dimple is a small pit or sinus in the hemangioma over the thoracic or lumbar spine sacral area just at the top of the gluteal fold (crease between the buttocks) • A dermal sinus or small tract which leads from the • It may also be a deep tract leading to a sinus skin surface down through to the spinal cord and cyst that may contain hair • May grow and the cyst may drain during • Blind sinuses or pits which do not lead into the adolescence (possible surgery) spine are common (up to 25%) and do not indicate underlying problems

• Only 2% of infants who have Spina Bifida Occulta have any symptoms or problems

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Extremities Newborn Assessment Assess ankles and feet for positional and structural malformations Genitourinary System • Positional • Metatarsus Adductus • Inward turning of front one third of foot • Talipes Calcaneovalgus • Leg and foot form shape of a checkmark rather than an L • Structural • Club foot (Talipes Equinovarus) - sole of foot turns medially and foot is inverted • The most severe form of “Club Foot” is fixed in position by bone and requires lengthy orthopedic treatment

Genitourinary • Genitalia is part of gestational age assessment Female Genitourinary • Assess for ambiguous genitalia • A white mucous discharge from vagina is • If present, refer to infant as “baby” not uncommon during the first week of life • Watch for and document first voiding • Pseudomenstruation • Should void within 24 hours of delivery • Pink-tinged mucous discharge • A rust colored stain on the diaper is a normal • Caused by withdrawal of maternal variation and caused by uric acid crystals in the urine hormones • Genitourinary anomalies and abnormalities in other • Lasts 2 to 4 weeks systems may be found i.e. cardiovascular, neurologic, gastrointestinal and/or musculoskeletal conditions • If there is a history of oligohydramnios or polyhydramnios there is most likely a genitourinary or renal impairment

Male Genitourinary Male Genitourinary Undescended Testes (Cryptorchidism) Physiologic Phimosis • Most common genital abnormality • Inability to retract the prepuce or foreskin at birth • May be unilateral or bilateral • By 3 years of age, foreskin can usually be retracted in • Will usually descend by 9 months of age in term males 90% of uncircumcised males because adhesions Hypospadius loosen • Second most common genitourinary abnormality • Meatus is on the ventral surface of the penis • In the uncircumcised penis the foreskin should not be • In some cases, associated with congenital syndromes retracted or forced away from the tip of the penis during Epispadius bathing or diaper care AWHONN, 2013 Skin Care Guideline • Meatus is on the dorsal surface of the penis Hydrocele • Enlarged scrotum from accumulation of fluid • Should disappear in 3 months

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Male Genitourinary Newborn Assessment Testicular Torsion • Twisting of testis on its spermatic cord Neurologic System • May occur prenatally • Usually unilateral • Hard, swollen scrotum which is red to bluish red in color and does not transilluminate • Compromises blood supply to testes • Requires urgent evaluation and possibly emergency management • Ischemia of more than 4-6 hours duration usually results in irreversible damage of loss of the gonad • Pain is not a universal finding in neonates

Reflex Elicit the reflex Normal Abnormal Suck By gently stroking the lips the Newborn will open his/her mouth Weak or absent response is seen with newborn and sucking movements begin premature infants, neurologic deficit, Neurological and Behavioral Assessment or CNS depression from maternal drug ingestion Rooting Stroke the cheek and corner of the The newborn’s head should turn Weak or absent response is seen with • Assessment through observation - alertness, newborns mouth toward the stimulus and open their premature infants, neurologic deficit, mouth or CNS depression from maternal drug resting posture, quality of muscle tone, motor ingestion

Palmar Grasp Stimulate the palmar surface of the The newborn should grasp the finger If the grasp is weak or absent in a activity and cry newborn’s hand with a finger and if the finger is pulled away the term newborn then cerebral, local infant should lead to a tighter grasp nerve, or muscle injury may be • A typical position for the newborn is partially present flexed extremities and legs abducted to the Tonic Neck Turn the newborn’s head to one side Extremities on the side the head is May indicate a neurologic injury if this when the newborn is resting in supine turned will extend and the opposite is a persistent response after four abdomen position extremities will flex months • Purposeless movements Moro Hold newborn in the supine position The newborn will abduct and flexes all An absence may indicate neurologic with head several centimeters off the extremities and may cry deficit or deafness bed, then withdraw the hand • Muscle tone supporting the head so the infant’s head falls back into the examiner’s • Tremors hand. Or expose to a loud noise. • Jitteriness • Neonatal seizure Babinski Stimulate the sole of the foot Extension or flexion of the toes occur Consistent absence of any response is abnormal and may indicate central depression or abnormal spinal nerve innervation

6 Normal Description of Sleep-Wake Cycles Sleep-Wake Cycles Picture A shows a newborn in deep or quiet sleep At term the infant spend almost 50% of his/her total sleep in active sleep and 45% in quiet sleep and about 10% is the transitional sleep between the two periods Picture B shows a newborn in the period of active rapid eye movement (REM). At term the infant spend almost 50% of his/her total sleep in active sleep and 45% in quiet sleep and about 10% is the transitional sleep between the two periods. Depending on the newborns age the amount of time spent in each sleep cycles will vary

Picture C shows a newborn in the drowsy or semidozing state. The newborn may have open or closed eyes, fluttering eyelids, slow and regular movements of the limbs. They tend to have a delayed response to external stimuli

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• Picture D shows the quiet alert or wide awake Periods of Reactivity state. The newborn is fully alert and follow First Period of Reactivity objects, faces, or auditory stimuli, but limited motor activity and still a delay in response to external stimuli May have some Lasts about nasal flaring and 30 minutes grunting • Picture E shows the active alert state. The after delivery newborns eyes are open, intense motor activity such as thrusting limbs, environmental stimuli increases the motor activity Heart rate and respirations are rapid Body • Picture F shows the crying state. There are jerky temperature is Muscles tone movements and intense crying. The newborn may decreased and motor activity are be hungry or in pain so the crying is used as a increased distraction and helps the newborn disburse energy and get a response from care givers

Periods of Reactivity Practice Questions Second Period of Reactivity 1. The nurse is assessing the neonate’s skin and notes the presence of small irregular red patches on the cheeks that will develop into single yellow pimples on the chest and/or abdomen. The name for this common neonatal skin condition is: A. Erythema toxicum The newborn Increased oral wakes and is mucus B. Milia alert C. Neonatal acne D. Pustular melanosis

Feedback: Erythema toxicum is a newborn rash that consists of small, irregular flat red patches on the cheeks that develop into singular, small yellow pimples appearing on the chest, abdomen, Tachycardia, and extremities. Acne, a skin condition common in adolescents, may also be present in newborns tachypnea, rapid and is related to excessive amounts of maternal hormones. Over time, neonatal acne disappears changes in color spontaneously from the infant’s cheeks and chest. Milia presents as small white papules or Will show signs of and muscle tone sebaceous cysts on the infant’s face that resemble pimples. Pustular melanosis is a condition in wanting to eat which small pustules are formed prior to birth. As the pustule disintegrates, a small residue or “scale” in the shape of the pustule is formed, and this lesion later develops into a small (1 to 2 More responsive mm) macule, or flat spot. Macules, which are brown in color, appear similar to freckles and are frequently located on the chest and extremities. Pustular melanosis occurs more commonly on to stimulation African American infants than on Caucasian infants.

2. The nursery nurse notes the presence of diffuse edema on baby 3. The perinatal nurse teaches the new mother and girl Patel’s head. Review of the birth record indicates that her her family about appropriate infant care to prevent mother experienced a prolonged labor and difficult childbirth. By the omphalitis. Information given would include: second day of life, the edema has disappeared. The nurse documents the following condition in the infant’s chart: A. Instructions for taking a rectal temperature A. Caput succedaneum B. Instructions to keep the base of the umbilical cord B. Cephalhematoma. clean and dry C. Epstein pearls C. Instructions to apply a mild soap and water solution to the cord D. Subperiosteal hemorrhage D. Instructions to change the diaper frequently during the first 24 hours following circumcision Feedback: Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. Feedback: The area around the base of the cord should be kept Cephalhematoma, a more serious condition, results from a subperiosteal clean and dry. During diapering, care must be taken not to allow hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant’s head and persists for weeks while the tissue stool or urine to come in contact with the cord or the cord base. If fluid is slowly broken down and absorbed. Epstein pearls are whitish, hardened this occurs, the nurse (or care giver) should carefully clean and nodules on the gums or roof of the mouth. dry the site. The tissue surrounding the base of the cord should be inspected for redness because this finding may indicate omphalitis, an infection that is readily treated with antibiotics.

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4. The perinatal nurse is aware that if a respiratory rate of 68 breaths per minute is noted in the newborn, the appropriate nursing actions would include: (Select all answers that apply) 5. As the perinatal nurse performs an assessment of the

infant’s head, ears, eyes, nose, and throat, the ears are A. Withholding the feeding B. Continuing assessment of the infant’s respiratory rate and noted to be low set. This clinical finding would require color follow up due to the potential for ______. C. Notifying the physician of additional signs or symptoms of respiratory distress Answer: Chromosomal abnormalities D. Documenting the infant’s chest measurement

Feedback: For healthy full-term neonates, a respiratory rate below 60 breaths per minute is considered normal. To obtain an accurate respiratory rate, it may be necessary to count Feedback: Special attention is paid to the shape, size, and the infant’s respirations at several different times during the physical assessment. If the placement of the ears. Low-set ears may signal the need for respiratory rate remains above 60 to 70 breaths per minute during rest, further evaluation is warranted. The nurse should withhold oral feedings if the respiratory rate is greater than further assessment and evaluation for chromosomal 60 respirations per minute. Additional signs of respiratory distress, such as flaring of the abnormalities. Placement of one ear slightly lower than the other nares, retractions (in-drawing of tissues between the ribs, below the rib cage, or above the sternum and clavicles), or grunting with expirations should be reported to the physician. is a common finding that generally has no clinical significance.

6. During the physical examination of a male neonate, the perinatal nurse notes that no bowel sounds can be 7. During the newborn assessment, the nurse notes asymmetry of the skin folds of the infant’s thighs in both the auscultated. The best action following this discovery is prone and supine positions. This finding may be an ______, a technique used to assess for the presence of indication of ______in the scrotal sac. Answer: Hip dysplasia Answer: Transillumination; fluid Feedback: Developmental dysplasia of the hip is a congenital condition that if left untreated can affect the infant’s future ability Feedback: If no bowel sounds are heard, transillumination to walk and maintain balance. It occurs when the acetabulum is flat, rather than round and cup-like in shape. The assessment can be used to verify the presence of fluid in the scrotal sac. begins with inspection of the skin folds on the infant’s thighs in The nurse secures a penlight or ophthalmoscope, which will both the prone and supine positions. Asymmetry of the skin folds be used as a light source, darkens the room, and gently may signal the presence of hip dysplasia. presses the light source against the scrotum. Fluid appears as a reddish-yellow reflection. Masses do not transilluminate and, if detected, must be reported immediately.

References References Davidson, M., London, M., & Ladewig, P. (2016). Old’s Simpson, K., & Creehan, P. (2014). AWHONN Perinatal Maternal Newborn Nursing & Women’s Health Across the Nursing (4th ed.). Philadelphia, PA: Wolters th Lifespan (10 ed.). Boston, MA: Pearson. Kluwer/Lippincott Willams & Wilkins.

Mattson, S., & Smith, J. (2016). Core Curriculum for Maternal- Tappero, E., & Honeyfield, M.E. (2015). Physical Assessment of the Newborn (5th ed.). Petaluma, CA: Newborn Nursing (5th ed.). St. Louis, MO: Elsevier. NICU Ink.

McKee-Garrett, T. (2016) Overview of the routine management of the healthy newborn infant. In M. Kim (ed). Up Tveiten L, Diep LM, Halvorsen T, Markestad T. Respiratory Rate During the First 24 Hours of Life in to date retrieved from http://wwwuptodate.com/home Healthy Term Infants. Pediatrics 2016; 13

http://newborns.stanford.edu/RNMDEducation.html

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References

Verklan, M. T. (2015). Adaptation to extrauterine life. Chapter 4 in Verklan and Walden AWHONN Core Curriculum for Neonatal Intensive Care Nursing, 5th edition. St. Louis: Elsevier Saunders

Venes, D. (2017). Taber's Cyclopedic Medical Dictionary, 23rd Edition (Thumb Index Version) 21st Edition. Philadelphia: F.A. Davis

Ward S. & Hisley (2016). Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children and Families (2nd ed.), Phildelphia: F. A. Davis

Ward, S. (2013). Pediatric Nursing Care: Best Evidence- Based Practices. Philadelphia: FA Davis.

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