NEWBORN ASSESSMENT

ASSESSMENT
General Measurements

NORMAL FINDINGS

a. Age

Term- start of 38th wk. end of

42nd week

b. Weight

6.5-6.75 lbs.

c. Length

18-20.5 inches / 45-52.3cm.

d. Apgar Score

7-10

POSSIBLE MAJOR DEVIATIONS AND

COMPLICATIONS
Preterm=before end of 37th week
Post term= after end of 42nd week
<6lbs, >9lbs
<7

Head Measurement
a. Shape

b. Size in relation to body

c.

Fontanels size, shape,

consistency

1. Anterior

2. Posterior

Round symmetrical; may have

moldingoverriding sutures;
slight asymmetry.
33-35cm
2cm>chest circumference
Sutures- palpable
Slight pulsation
Soft
3-4cm long
2-3cm wide
Diamond shape
1-2cm
Triangular

Microcephaly <32cm
Hydrocephaly >4cm from chest
Cephalohematoma
Full bulging, large, depressed
Closed sutures

Eyes
a. Color

Black iris, white sclera

Jaundiced sclera

b. Movement

Random, jerky, uneven. Focus

momentarily. Follows to midline

c. Reaction to Light

Pupils equal in size, round and

reactive to light. May turn toward
soft light.
Without or occasionally

Gross nystagmus
Constant Strabismus
Dolls eye
Pupils unequal, restricted, dilated, fixed

d. Tears

Discharge

e. Evidence of sight

Focuses and follows by 15min of

age.; reactive to light

Does not respond to light, focus of follow

f. Eyelids

Size ang movement symmetric.

Blink reflez. Edema from
prophylaxis. Eyes on a parallel
plane.

Does not respond to light, focus, or follow

Startle reflex to loud noise.

Attends to sound. By 15min. of
age may move eyes in direction
of sound. Responds to crooning
by relaxation
Line drawn through inner and
outer canthi of eye comes to top
notch of ear (where it connects
with scalp.)symmetrical.
Evidence of hearing. Reaction to
noise.
Midline
Clear
Infants obligatory nose breathers.
Sneezing is common

Absence of reaction.

Ears
a. Reaction to noise

b. Position

c. Patency
Nose
a. Mucus
b. Patency
c. Reflexes
1. Sucking
2. Swallow
3. Gag
Mouth

Neck
a. Length
b. Mobility

Chest
a. Size

Low placement

Copius drainage
Cyanosis at rest.
Flaring or nares.

Dependent on state of
wakefulness and hunger.

Symmetrical
Presence of gag and swallowing
reflex
Hard and Soft palate intact
Epsteins Pearls

Mouth drawls to one side

Short, thick, surrounded by skin

folds
Head held midline. Free
movement from side to side. Full
flexion and extension. Cannot
move head past shoulder.

Webbing

1-2cm < head circumference

<30 cm

Clefts

Rigid
Restricted movement
Head held at angle.
Without head control.

Notes

b. Breast tissue
c. Characteristic shape

30-33cm
3-10mm breast nodule
Nipple prominent
Almost circular
Barrel shaped.

Lack of breast tissue

Bulging of chest
Retractions
Bowel sounds in chest

Respirations
a. Rate

30-60/min

b. Rhythm

Shallow
Irregular when infant is awake
No sounds heard without
stethoscope
Bronchial. Loud, clear
Simultaneous rise and fall of
chest and abdomen.
Diaphragmatic and abdominal
breathing.

c. Breath sounds
d. Muscular activity involved

Pulse
a. Rate

b. Rhythm
c. Peripheral Circulation

Arms and Hands

a. Length
b. Movements

c. Muscle tone

Persistent tachycardia - >170

Bradycardia - <120

Femoral pulses palpable, equal,

strong. Sluggish peripheral
circulation.

Weak or absent.

Arms equal in length.

Arms longer than legs.
Spontaneous
Full range of motion

Anelia phocomelia

Generally flexed. Fist often

clenched with thumb under
finger.

Correct

2. Webbing

Without webbing

e. Position

Fists often clenched with thumb

under finger.

Umbilical Cord
a. Number of vessels at birth

Grunting, rales, rhonchi, wheeze (with or

without stethoscope)
Apnea >15sec.
Subcostal and substernal retractions.
Flaring of nares. Chin tug.

120-160/min
180 with crying
100/min if asleep
May be irregular for brief periods
especially after crying

d. Fingers
1. Number

Abdomen
a. Contour
b. Musculature

Tachypnea >60/min
Bradypnea <25/min
Labored breathing

Rounded, protruding
Not fully developed. Bowel
sounds audible 1-2 hours after
birth

b. Appearance

2 arteries
1 vein
Clear gelatin, odorless, drying

Genitourinary
a. Female
1. Labia

Usually edematous

Persistent irregular rhythm.

Limited movements. Asymmetry of

movements.
Tonicity
Asymmetric contour.
Poor tone/floppy
+scarf sign.

Absence of or additional.
Short
Polydactyl
Syndactyl
Rigid flexion.
Persistent fists
Abdominal distended scaphoid
Sounds in chest.

Bleeding or oozing; drainage or redness

Ambiguous genitals

a.size

Covers labia minora

Labia majora widely separated

b.appearance

May have pigment.

Symmetric in size

Minora prominent.

2. Vaginal discharge
a.color
b.type

Absence of vaginal orifice

Fecal discharge
Smegma under labia. May be
blood tinged
Mucoid/white

b. Male

Ambiguous genitals

1. Testes in scrotum

Palpable each side

Large. Rugge. Cremasteric

Undescended
Scrotum smooth.

2. Urethral meatus at end of penis

Correct position
Prepuce covers glans.
Not easily retractable.

Not at tip of penis

Adherent prepuce.

c. Voidings

1. Color
2. Amount
3. Frequency
4. Specific gravity

Clear, light yellow

Well saturated diapers
By 24 hrs after delivery. At least
3-4 times/day
1.008-1.010

Rectum
a. Patency
b.
1.
2.
3.
4.

Stools
Number
Color
Consistency
Frequency

Hips
a. Symmetry
b. Femur heads

Good sphincter tone of anus.

Good wink reflex.
Meconium by 24 hrs. after birth
Depends on age of infant and
type of feeding she is receiving.

Gluteal folds even

Intact
No protrusions

Failure to pass meconium

Abdominal distention
Diarrhea curdy, green, large water ring,
forceful.

Congenital hip dysplasia.

Back
a. Appearance

Straight, easily flexed

b. Turns head from side to side in

prone position

Yes
Can raise head momentarily

Limitation of movement.
Pigmented nevus with tuft of hair located
at base of spine.
Spina bifida.

Legs and Feet

a. Appearance

May appear to have bowed legs

b. Warmth

Equal

Different temperatures

c. Length

Legs of equal length. Shorter

than arms
Full ROM

Unequal.

d. Movement
e. Alignment

f. Muscle tone
g. Toes
1. Number
2. Webbing
h. Position
Skin
a. Color

b. Textures

c. Birthmarks

Foot in straight line. May appear

to turn in but easily rotated
externally.
General flexion
Feet flat. Well lined over 2/3 of
surface
Correct

Hypermobility
Lack of leg movement
Club foot.

Absent or excessive digits.

Without webbing
General flexion. Most often see
legs drawn up against abdomen

Syndactyl
Rigid of floppy posture

Generally pink. Acrocyanosis.

May see some mottling.

Jaundice
Cyanosis
Pallor or dark red.
Thinner or thicker texture.
Fish scale skin.

Smooth, soft. Flexible. May have

dry peeling hands and feet.
Without edema.
Teleangiectases
Mongolian spots
Transient hyperpigmentation of
areolas, genitals.

Hemangiomas

d. Characteristics
1. Milia

Distended sebaceous glands

particularly on nose and cheeks

2. Lanugo

Over shoulder, pinniias,

forehead, back
White, cheesy, odorless
substance in creases and folds

Absent or excessive

4. Ecchymosis

Petechiae over presenting part.

Ecchymosis from forceps

Over other areas.

5. Hair

Amount varies. Silky, growth

pattern toward face and neck.

Fine, woolly, coarse, brittle, unusual

growth pattern.

6. Nails

Present, extended beyond

fingertips
Of hands and feet at about day 3.

Absence

3. Vernix Caseosa

7. Peeling

Absent or excessive; yellow, green or foul

odor.

Generalized cracking and/ or peeling.

Temperature
97.6-98.6F axillary

Hypothermia/Hyperthermia

a. Temperature regulatory
mechanism

Normal

Shivering mechanism
undeveloped. Brown fat.

Temperature not stabilized by 10hrs after

birth.

b. Heat Loss

From evaporation, conduction,

convection, radiation.

Swings of >2F from one reading to the

next.

Reflexes
a. Local
1. Blink

2. Pupillary
3. Dolls eyes
4. Rooting
5. Sucking/ swallowing
6. Gag
7. Yawn
8. Grasp
9. Babinski

Response to light stimulus. Tap

on forehead, bridge of nose,
maxilla when eyes open-blink
first 4-5times.
Response to light is equal.
Round. Pupil constricts
When head is turned, eye
movement lags behind.
Turns head in direction of
stimulus; opens mouth

Continued blinking with repeated taps.

Follows rooting. Takes hold,

sucks and obtains fluids.
Safety reflex. Do not try to elicit.
Spontaneous
Finger curl around examiners
finger. Toes turn downward.

Weak or absent. Gagging, coughing, or

vomiting with swallowing

Hyperextension of all toes with

dorsiflexion of big toe when one
side of sole is stroked from heel
across ball of foot to toe.

Absent

Failure to respond. Response unequal.

Weak or absent.

b. Generalized
1. Moro (startle)

Symmetric abduction and

extension of arms.
Finger may fan with forefinger
and thumb forming a C. Arms
then adduct in embracing motion
and return to relaxed flexion.

2. Tonic neck (fencing)

When head is turned to one side,

extremities on same side extend
and on opposite side flex.
When held upright with one foot
touching a flat surface, will
stimulate walking. Will step
alternately.
While on abdomen, will make
crawling movements with arms of
legs.

3. Dance/ walking

4. Crawling

Asymmetry of stepping

Absent.

c. Assess the newborn for:

1. Presence or absence of each
reflex.
2. Strength of each reflex
3. Infants response to your
assessment.
Cry
a. Frequency

Individual 15-20min q 24 hrs to

2hrs q 24hrs.

Unconsolable.

b. Pitch

Lusty, strong, moderate pitch.

High pitch.
Weak or absent

Personality and Behavior

a. Response to handling
b. Reactions to environment

c. Parent-infant interaction

d. Eating-Sleeping patterns

Touch, massaging, warmth

-soothing
Low pitch voice- relaxation
Responds with quietness and
increased alertness and cuddling
voice.
Turns head and focuses when
interested. Coordinates body
movement to parents voice and
body movement
Variations in interest/ hunger.
Usually feeds well within 24hrs.
Wakeful periods about q 3-4
hours.

Unconsolable.

No focus on person handling

Lethargy

APGAR SCORING