ASSESSME NORMAL ABNORMAL Auscultate apical Pulse is regular and

within a range of
An irregular pulse or a
rate above 180
pulse
NT FINDINGS FINDINGS 120-140 beats/min beats/min while crying
while at rest. or below 100 beats/min
APGAR SCORE Therate may rise to while sleeping may
Assign Apgar Assess the A score of less than 8 180 beats/min when indicate cardiac
following: The may indicate poor crying or fall to 100 abnormalities
scores at 1 and at beats/min when
score is 8–10. transition from
5 minutes after intrauterine to sleeping
delivery. The extrauterine life. MEASUREMENTS
Apgar score is an Weigh the The newborn Weight is less than
assessment of the newborn using a weighs between 2500 g or greater than
2500 and 4000 g 4000 g.
infant’s ability to newborn scale.
adapt to The chid should
extrauterine life. be unclothed
Assess the Measure length The newborn is 44- Length Is less than 44
following 55 cm or greater than 55cn
Pulse is greater than Pulse is less than 100 Measure head Circumference is Circumference is less
Auscultate Apical
100 bpm bpm, indicating circumference 33-35.5 cm than 33 cm or greater
Pulse than 35.5 cm. May
bradycardia. Absent
heart beat indicates indicate microcephaly,
fetal demise. improper brain growth,
The newborn is The newborn has premature closing of
Inspect chest and the sutures, intrauterine
abdomen for crying absent, slow, or
irregular respirations. infection or
respiratory effort chromosomal defect
Stroke back or Crying Delayed neurologic Measure chest Circumference is Circumference is less
soles of feet function may be seen in 30-33 cm (1-2 cm than 29 cm or greater
circumference.
grimace, no response. less than head) than 34 cm
The full body The newborn is Place tape
Inspect body and
shoudbe pind, but cyanotic, pale measure at nipple
extremities for
acrocyanosis is line and wrap
skin color common in around infant
newborns whether GESTATIONAL AGE
preterm or ful term Arms and legs are In premature children,
Inspect posture
VITAL SIGNS flexed. the newborn’s arms and
Breathing is easy Abormal Findings (with the
Inspect and legs may be limp and
and nonlabored. The include labored newborn extend away from the
auscultate lung
lungs are clear breathing, nasal flaring, undisturbed) body.
sounds bilaterally rhonchi, rales,
Assess for square Angle is 0–30 Premature newborns
retractions, or grunting. may have a square
Rate is 30-53 A rate less than 30 or window sign.
Monitor window measurement
breaths/min greater than 60 Bend the wrist of less than 30°
respiratory rate.
Breaths/min is seen toward the
with respiratory distress ventral forearm
until resistance is and proximity of
met. Measure the heel to the
angle. ear.
Test arm recoil. Elbow angle is less In premature children, TO ASSESS FOR PHYSICAL MATURITY
Bilaterally flex than 90° and the arm elbow angle may be Inspect the skin. Inspection reveals Inspection reveals
rapidly recoils to a greater than 110° and parchment, few or translucent, visible
elbows up flexed state. delayed recoil may be no vessels on the veins; rash; leathery,
seen. abdomen, and wrinkled skin that is
Assess popliteal The angle should be Premature children may crackling, especially seen in most postmature
angle. Flex the less than 100°. have a popliteal angle in the ankle area. children.
of greater than 100°. Inspect for Normally there is In premature children,
thigh on top of thinning and balding abundant amounts of
the abdomen; lanugo.
on the back, fine hair may be seen
push behind the shoulders, and on the face.
ankle and extend knees.
the lower leg up Inspect the There are creases on Transverse crease on
plantar surface of the anterior two sole only, no creases, or
towards the head thirds or entire sole fewer creases indicate
until resistance is the feet for prematurity
met. Measure the creases.
angle behind the Inspect and The areola is raised In premature infants,
palpate breast and full. there may be an
knee.
absence of breast tissue
Assess for Scarf Elbow position is In premature children, bud tissue with and a bud less than 3
sign. Lift the arm less than midline of elbow position is at the middle finger mm.
the chest (Fig. 30- midline of the chest or
across the chest and forefinger;
10A). greater (toward
toward the opposite shoulder measure bud in
opposite shoulder millimeters.
until resistance is Observe ear Normally you find a With prematurity, you
cartilage in the well-curved pinna, may find a slightly
met; note location
wellformed curved pinna and slow
of the elbow in upper pinna for cartilage, and instant recoil.
relation to curving. Fold the recoil.
midline of the pinna down
chest. toward the side of
Perform heel-to- Popliteal angle is In premature infants, the head and
ear test. Keeping less than 90°; the popliteal angle may be release; note
heel is distal from greater than 90°, and
buttocks flat on recoil of the ear
the ear. the heel may be
the bed, pull leg INSPECT THE GENITALS
proximal to the ear.
toward the ear on Male: Assess Male: There are Male: There is
scrotum for deep rugae; testes decreased presence of
the same side of are positioned down rugae; testes are
the body; inspect rugae and in scrotal sac. positioned in upper
popliteal angle inguinal canal.
 palpate position physical
of testes. assessment in
Female: Inspect Female: The labia Female: In prematurity, infants.
labia majora, majora covers the the labia majora and Growth and Gross and fine Gross and fine motor
labia minora and labia minora are equally motor skills should skills that are
labia minora, and clitoris. prominent and the development of
be appropriate for inappropriate for
clitoris. clitoris is prominent. the newborn/ the child’s developmental age and
Determine score Score totals 35–45. Score totals less than 35 infant may be developmental age. lack of head control by
rating: Use or greater than 45. assessed using the Head control should age 6 months may
Figure 30-11. Denver be acquired by 4 indicate cerebral palsy.
Developmental months of age. Hand Hand preference that is
Mark the boxes preference is not developed during
that most closely Screening Test . developed during preschool years may
represent each This test is used the preschool years. indicate paresis on
observation. to guide the nurse opposite side.
GENERAL APPEARANCE AND BEHAVIOR to the
Observe general Child appears stated Note any facies that appropriate
appearance. age; is clean, has no indicate acute illness, developmental
unusual body odor, respiratory distress.
Observe hygiene. milestones for the
and clothing is in Flaccidity or rigidity in
Note interaction good condition and newborn may be from child’s gross
with parents and appropriate for neurologic damage, motor, language,
yourself (and climate. Child is sepsis, or pain. Poor fine motor, and
siblings if alert, active, hygiene and clothes personal social
responds may indicate neglect,
present). Note development.
appropriately to poverty. Infant does not
also facies (facial VITAL SIGNS
stress of the appear stated age
expressions) and Assess Temperature is Temperature may be
situation. Child is (mental retardation,
temperature. Use 99.4°F (because of altered by exercise,
posture. appropriately abuse, neglect).
excess heat stress, crying,
interactive for age, rectal, axillary, production). environment, diurnal
seeks comfort from skin, or tympanic variation (highest
parent; appears
happy. Newborn’s
route when between 4 and 6 PM).
assessing the Both hyperthermic and
arms and legs are in
temperature of hypothermic conditions
flexed position.
are noted in infants.
DEVELOPMENTAL ASSESSMENT an infant.
Screen for Infant meets normal Child lags in earlier The rectal
cognitive, parameters for age stages.
(see information
temperature is
language, social, contained in most accurate. To
and gross and subjective data take a rectal
fine motor section temperature in a
developmental newborn, lay the
delays in the child supine and
beginning of the lift lower legs up
 into the air, 180 beats/min. Rate cardiac/respiratory
bending the legs decreases gradually problems or sepsis.
with age. At 6
at the hips. Insert months to 1 year,
lubricated rectal rate is
thermometer no approximately 110
more than 2 cm beats/min.
into rectum. Assess Neonates: Rate is Respiratory rate and
respiratory rate 30–60 breaths/min. character may be
Temperature Breathing is altered by medications,
registers in 3–5 and character. unlabored; lung positioning, fever, and
min on a rectal Measure sounds clear. activity, as well as
thermometer. respiratory rate Newborns are pathologic conditions.
Axillary and/or and character in obligatory nose Retractions, see-saw
infants by breathers. respirations, apnea
tympanic greater than 15 seconds,
temperature may observing grunting, nasal flaring,
also be used. For abdominal stridor, rale, tachypnea
axillary movements. greater than 60
temperature, breaths/min should be
further evaluated for
place the respiratory distress.
thermometer Evaluate infant Normal findings are
under axilla, blood pressure, if specific to age and
holding arm close size
necessary.
to chest for MEASURE LENGTH.
approximately 3– Determine height For normal findings Significant deviation
5 minutes. For by measuring the see the growth from normal in the
tympanic charts available at growth charts would be
recumbent http://www.cdc.gov/ considered abnormal.
temperature, use length. Fully growthcharts.
digital tympanic extend the body, CULTURAL
thermometer as holding the head CONSIDERATION
directed in in midline and S Asian and African
manufacturer’s gently grasping
American newborns
are smaller than
instructions. the knees, Caucasian
Note apical pulse Awake and resting Pulse may be altered by
pushing them newborns. Asian
rate. Count the rates vary with the medications, activity,
downward until children are smaller
age of the child. For and pain as well as
pulse for a full a newborn to 1- pathologic conditions. the legs are fully at all ages
minute month-old child, it Bradycardia (<100 extended and
should be 120–160 beats/min) in an infant touching the table
beats/min. When is usually an ominous
(Fig. 30-13). If
crying, the heart rate finding. Tachycardia
may increase up to may also indicate using a
measuring board, age- and gender-
place the head at appropriate
the top of the growth chart.
board and the Determine HC (OFC) Abnormal
heels firmly at the head/chest measurement should circumference of head
fall between the 5th include less than 29 cm
bottom. Without circumference. and 95th percentiles and greater than 34 cm.
a board, use Measure head and should be HC (OFC) not within
paper under the circumference comparable to the the normal percentiles
infant and mark (HC) or occipital child’s height and may indicate pathology.
the paper at the frontal weight percentiles. Those greater than 95%
Chest circumference may indicate
top of the head circumference is not normally macrocephaly. Those
and bottom of the (OFC) at every measured after the under the 5th percentile
heels. Then physical newborn period but may indicate
measure the examination for continues to microcephaly
distance between infants and increase in size.
the two points. toddlers younger
Plot height than 2 years and
measurement on older children
an ageand when conditions
gender- warrant. If
appropriate necessary,
growth chart determine chest
Measure weight. See the growth Deviation from the circumference by
Measure weight charts available at wide range of normal measuring the
http:// weights is abnormal.
on an www.cdc.gov/growt Compare differences by chest at the
appropriately hcharts for normal referencing the growth nipple line. Plot
sized beam scale findings. charts available at the
with http://www.cdc.gov/gro measurements for
nondetectable wthcharts. both the head and
weights. Weigh chest on
an infant lying or standardized
sitting on a scale growth charts
that measures to specific for
the nearest 0.5 oz gender from
or 10 g (Fig. 30- birth to 36
14). Weigh an months.
infant naked. Plot SKIN, HAIR, AND NAILS
weight
measurement on
 Assess for skin Skin color ranges Yellow skin may any unusual hair shoulders, back, and
color, odor, and from pale white with indicate jaundice or on body. sacral area—may
pink, yellow, brown, passage of meconium in been seen in the
lesions. or olive tones to utero secondary to fetal newborn or young
dark brown or black. distress. Jaundice infant.
Acrocyanosis within 24 hours after Inspect and CULTURAL Blue nailbeds indicate
(sluggish perfusion birth is pathologic and palpate nails. CONSIDERATION cyanosis. Yellow
of peripheral may indicate hemolytic S Dark-skinned nailbeds indicate
circulation) may be disease of the newborn. Note color, children have deeper jaundice. Blue-black
present. Mottling Blue skin suggests texture, shape, nail pigment. Nails nailbeds suggest a
(general red/white cyanosis, pallor and condition of extend to end of nailbed hemorrhage.
discoloration of the suggests anemia, and nails. fingers or beyond,
skin) may be noted redness suggests fever, and are well-formed.
when chilled. No irritation. Ecchymoses HEAD, NECK, AND CERVICAL LYMPH NODES
strong odor should in various stages or in Inspect and Head is A very large head is
be evident, and the unusual locations or
skin should be circular burn areas
palpate the head. normocephalic and found with
symmetric. In hydrocephalus. An
lesion free. suggest child abuse. Note shape and newborns, the head oddly shaped head is
CULTUR Petechiae, lesions, or symmetry. In may be oddly found with premature
rashes may indicate newborns, inspect shaped from closure of sutures
blood disorders or and palpate the molding (overriding (possibly genetic). One-
neurologic disorders. of the sutures) sided flattening of the
condition of
Palpate for Skin is soft, warm, Pallor, ruddy during vaginal birth. head suggests
and slightly moist. complexion, and fontanelles and The diamond- prolonged positioning
texture, sutures
Vernix caseosa jaundice should be shaped anterior on one side. A third
temperature, (cheesy, white further evaluated for fontanelle measures fontanelle between the
moisture, turgor, substance that is cardiac anomalies and about 4–5 cm at its anterior and posterior
and edema. found on the skin, blood disorders. widest part; it fontanelle is seen with
especially in skin usually closes by Down’s syndrome.
folds) is a common 12–18 months. The Premature closure of
finding; it triangular posterior sutures
eventually absorbs fontanelle measures (craniosynostosis) may
into the skin. Skin about 0.5–1 cm at its result in caput
turgor should have widest part and succedaneum (edema
quick recoil. Edema should close at 2 from trauma), which
may be present months of age. crosses the suture line,
around the eyes and and cephalohematoma
genitalia of the (bleeding into the
newborn. periosteal space), which
Inspect and Hair is normally Dirty, matted hair may does not extend across
palpate hair. lustrous, silky, indicate neglect. Tufts the suture line (Fig. 30-
strong, and elastic. of hair over spine may 17). Craniotabes may
Observe for Lanugo—fine, indicate spina bifida result from osteoporosis
distribution, downy hair that occulta. of the outer skull bone.
characteristics, covers parts of the Palpating too firmly
and presence of body, such as the with the thumb or
 forefinger over the nodes for Lymph nodes are IFficulty breathing. s
temporoparietal area swelling, usually nonpalpable %NLARGEDTHYROI
will leave an in infants. Clavicles DORPALPABLEMAS
indentation of the bone. mobility, are symmetrical and SESSUGgest a
Bulging fontanelle temperature, and intact. pathologic process. s
indicates increased tenderness. 3HIFTINTRACHEALP
cranial pressure. OSITIONFROMMIDL
Microcephaly is seen INE suggests a serious
with infants who have lung problem (e.g.,
been exposed to foreign body or tumor).
congenital infections. s
Test head control, Full ROM—up, Hyperextension is seen #REPITUSWHENCLA
head posture, and down, and with opisthotonos or VICLEPALPATEDAL
sideways—is significant meningeal ONG with decreased
ROM. normal. Infants irritation. Limited range movement in arm of
should have head of motion may indicate that side mate fractured
control by 4 months torticollis (wry neck). clavicle.
of age. Inspect the Inner canthus Wide-set position
Inspect and Face is normally Unusual proportions external eye. Note distance (hypertelorism), upward
palpate the face. proportionate and (short palpebral approximately 2.5 slant, and thick
symmetric. fissures, thin lips, and
the position, cm, horizontal slant, epicanthal folds suggest
Note appearance, Movements are wide and flat philtrum, slant, and no epicanthal folds. Down’s syndrome.
symmetry, and equal bilaterally. which is the groove epicanth Outer canthus align “Sun-setting”
movement. Parotid glands are above the upper lip) with tips of pinna appearance (upper lid
Palpate the normal size. may be hereditary or covers part of the iris)
parotid glands they may indicate suggests hydrocephalus
specific syndromes
for swelling such as Down’s
syndrome and fetal
alcohol syndrome. Observe eyelid eyelids have eyelids inflammation ay
Unequal movement placement, swell transient edema, result from infection,
may indicate facial absence of tears swelling, erythema, or
nerve paralysis. purulent discharge imay
Abnormal facies may indicate infection or
indicate chromosomal blocked tear ducts
anomaly. Purulent discharge seen
The neck is usually Implications of some with secually
Inspect and
short with skin folds abnormal findings transmitted infections
palpate the neck. (gonorrhea, chlamydia)
between the head include the following:
Palpate the and shoulder during sHORTWEBBEDNEC Inspect The Sclera and yellow sclera suggests
thyroid gland and infancy. The KSUGGESTSANOMA sclera and conjunctive a clear jaundice, blue sclera
trachea. Also isthmus is the only LIES or syndromes and free of may indicate
conjunctive for discharge, lesions, osteogenesis imperfecta
inspect and portion of the such as Down’s
thyroid that should syndrome. s
color discharge, redness, or (brittle bone disease
palpate the lesions, redness laceratons. Small
be palpable. The $ISTENDEDNECKVE
cervical lymph trachea is midline. INSMAYINDICATED and lacerations subconjunctival
 hemorrhage may be examination. The serious defects of is unusual in children of
seen in newborns. procedure is the the cornea, aqueous this age owing to the
Observe the iris Typically, the iris is Brushfield’s spots may chamber, lens, and ability of the
blue in light-skinned indicate Down’s
same as for vitreous humor. fontanelles and sutures
and the pupils. adults.
infants and brown in syndrome. Sluggish When visualized, to open during
dark-skinned pupils indicate a Distraction is the optic disc increased intracranial
infants; permanent neurologic problem. preferred over appears similar to an pressure. Disc blurring
color develops Miosis (constriction) the use of adult’s. A and hemorrhages
within 9 months. indicates iritis or newborn’s optic should be reported
Brushfield’s spots narcotic use or abuse.
restraint, which is discs are pale; immediately. Abnormal
(white flecks on the Mydriasis (pupillary likely to result in peripheral vessels findings include
periphery of the iris) dilation) indicates crying and closed are not well congenital defects, such
may be normal in emotional factors (fear), eyes. Careful developed as cataracts.
some infants. Pupils trauma, or certain drug ophthalmoscopic
are equal, round, use.
and reactive to light
examination of
and accommodation newborns is
(PERRLA). difficult without
Inspect the Eyebrows should be Sparseness of eyebrows the use of
eyebrows and symmetric in shape or lashes could indicate mydriatic
and movement. skin disease.
eyelashes They should not
medications
EARS Inspect Top of pinna should Low-set ears with an
meet midline.
external ears. cross the eye- alignment greater than a
Perform visual Visual acuity is ject. Children with a
occiput line and be 10-degree angle (Fig.
acuity tests. difficult to test in one-line difference Note placement, within a 10-degree 30-18, p. 716) suggest
infants; test by between eyes should be lesions of the ears
Assess visual observing the referred for
angle of a retardation or
acuity by perpendicular line congenital syndromes.
infant’s ability to fix ophthalmology
drawn from the Abnormal shape may
observing infant’s on and follow
eyeocciput line to suggest renal disease
ability to gaze at objects.
the lobe. No unusual process, which may be
an object. structure or hereditary. Preauricular
Perform . In the Hirschberg Unequal alignment of markings should skin tags or sinuses
extraocular test, the light light on the pupils in appear on the suggest other anomalies
reflects the Hirschberg test of the ears or renal
muscle tests. symmetrically in the signals strabismus. Inspect internal No excessive Presence of foreign
Hirschberg test: center of both pupils Doll’s eye reflex is an cerumen, discharge, bodies or cerumen
Shine light abnormal reflex that
ear. The internal
lesions, impaction. Purulent
directly at the occurs when the eyes ear examination excoriations, or discharge may indicate
cornea while the do not follow or adjust requires an foreign body in otitis externa or
infant looks
to movement of the otoscope. The external canal. presence of foreign
head nurse should Amniotic body. Purulent, serous
straight fluid/vernix may be discharge suggests
always hold the
present in canal of otitis media. Bloody
Perform Red reflex is Absence of the red otoscope in a the ear of the discharge suggests
ophthalmoscopic present. This reflex reflex indicates manner that newborn. Tympanic trauma, and clear
rules out most cataracts. Papilledema allows for rapid membrane is pearly discharge may indicate
 removal if the gray to light pink, cerebrospinal fluid leak. soothing when held “cocaine babies.”
child moves. with normal Perforated tympanic in the en face Infantile reflexes
landmarks. membrane may also be position present when
Have the Tympanic noted. inappropriate, absent, or
caregiver hold membranes redden asymmetric may
and restrain the bilaterally when indicate a CNS
child. Because an child is crying or problem.
infant’s external febrile Test deep tendon infantile reflexes are Absence or marked
and superficial present when intensity of these
canal is short and appropriate, and are reflexes, asymmetry,
straight, pull the reflexes. symmetric. The and presence of
pinna down and Babinski response is Babinski response after
back normal in children age 2 years may
Hearing acuity. A newborn will No reactions to noise younger than 2 years demonstrate pathology.
exhibit the startle may indicate a hearing (this response
In the infant, test usually disappears
(Moro) reflex and deficit. Audiometry
hearing acuity by blink eyes (acoustic results outside normal between 2 and 24
noting the blink reflex) in range suggest hearing months), and triceps
reaction to noise. response to noise. deficit. reflex is absent until
Stand Older infant will age 6. Ankle clonus
turn head. (rapid, rhythmic
approximately 12 plantar flexion) in
inches from the response to eliciting
infant and create ankle reflex is
a loud noise common in
Inspect mouth Epstein’s pearls— White discharge noted newborns.
and throat. Note small, yellow-white on the tongue or buccal
retention cysts on mucosa is thrush. Cleft
the condition of the hard palate and lip and/or palate are
the lips, palates, gums—are common congenital
tongue, and in newborns and abnormalities.
buccal mucosa. usually disappear in
the first weeks of
life. In infants, a
sucking tubercle
(pad) from the
friction of sucking
may be evident in
the middle of the
upper lip
Assess the The newborn’s and Inappropriate response
newborn’s and infant’s cries are to stimuli suggests CNS
lusty and strong; disorders or problems.
infant’s cry, responds An inability to quiet to
responsiveness, appropriately to soothing and gaze
and adaptation. stimuli and quiets to aversion is seen in