Newborn Assessment

INITIAL RAPID ASSESSMENT OF NEWBORN

This module focuses on assessment of the newborn infant. The assessment begins at birth and is done periodically by the nurse during the next two to four days. This eLearning module will describe assessment techniques and normal variations in newborn appearance.

After the infant is born, your initial assessment is quick and will occur at the same time you are drying and warming the infant for placement on the mother's chest for skin-to-skin contact or under the warmer. Don't forget to wear gloves until after the infant has been bathed. The infant is wet with amniotic fluid and slippery and may be a bit bloody.

Your initial assessment is primarily listening and observation.

• What do you hear?
• Is the baby crying? (See picture above. This is a good sign!)
• Is the baby grunting or singing? (This can be a sign of respiratory distress).
• Click here to listen to grunting.
• What do you see?

• What is the overall body color?
• Pink? (See picture above. This is a good sign!)
• Pale? Ruddy? Blue? (Not a good sign).
• Or are only the feet and hands blue? (See picture above. This is a normal finding in the first 24 hours).
• What is the tone and position of the body?
• Are the legs and arms pulled into the body? (See picture above. This is a good sign!)
• Are the legs and arms limp? (See picture below-not a good sign! ).

This infant shows little muscle tone of arms and legs.

• How is the respiratory effort?
• Is the infant breathing? (A good sign!)
• Does the chest rise and fall? (A good sign!)
• Are there substernal or intercostal retractions? (May are signs of respiratory distress).

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

This infant shows substernal retractions and intercostal retractions. These are signs of respiratory distress.

• Is there nasal flaring?

Left picture is normal.

Right picture shows nasal flaring. This can be a sign of respiratory distress.

APGAR SCORE

• The APGAR SCORE is a quick test performed on the newborn at one and five minutes after birth.
• The one minute score assesses how well the infant tolerated the birth. The five minute score assesses how well the infant is adapting to the new environment.
• Five areas are assessed: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). If the infant has a strong cry, the respiratory effort receives a top score of 2.
• Each area receives a 0 to 2 score with a maximum total of 10 points.
• The test identifies infants who need medical attention to stabilize heart or breathing function.
• Most infants score between eight and ten.
• If the delivery is difficult, the infant may receive less than adequate oxygenation. A lower initial apgar score may result.
• Fewer than 2% of infants have an apgar score of less than seven at five minutes.

•  To elicit a grimace, the infant is lightly pinched. If there is grimacing or a vigorous cry and a cough or sneeze, the infant scores a 2 for Grimace or reflex activity.
• To receive a score of 10, the infant will be completely pink, have a heart rate > 100, grimace (make a face) and cough or sneeze, actively move and flex arms and legs and have a strong cry and good (30-60) respirations.
• An newborn with all of the above but with blue feet or hands receives a 9 out of 10 Apgar score.

 Healthy Response to Birth

• If the infant is pink, the arms and legs are actively pulled toward the body, the baby is crying and does not have retractions or nasal flaring, the infant may be placed skin-to-skin on the mother's chest. If the mother in unable to hold the infant, it may be placed skin-to-skin on the father's chest. See side panel for benefits of early skin-to-skin contact.

At Risk Response to Birth

• If the infant is not breathing or has not cried, neonatal resuscitation will be needed. This begins with stimulation of the infant and oxygen by mask. If the infant does not cry or breathe, an endotrachial tube may be inserted to provide oxygen to the lungs, chest percussions may be initiated and the infant will quickly be transported to the NICU (neonatal intensive care unit).
• If the infant has signs of respiratory distress such as nasal flaring, retractions, grunting and rapid respirations, the infant will be monitored closely under the warmer and will not be placed skin-to-skin until these signs are gone.

VITAL SIGNS

Vital signs for the infant include heart rate, respirations and temperature. Initially the vital signs are monitored every half hour for the first two hours after birth. After stabilization, newborn assessments including vital signs occur every four to eight hours.

It is easiest to assess the heart rate and respirations while the infant is quiet. If the infant is crying, you may try to calm the infant by wrapping and rocking the infant. You may also insert a clean, gloved finger into the infant's mouth. The infant's suck will be initiated and the infant will quiet.

Heart Rate

Auscultate the apical heart rate at the border of the left sternum for a full minute.

Note: The PMI of the infant's heart is lateral to the midclavicular line at the left lower sternal border at the 4th ICS whereas the adult's PMI is at the 5th ICS (see pictue on the right).

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA Elsevier

The infant's normal heart rate is 120-160 beats per minute and irregular. During sleep the heart rate may decrease to 100. After birth or while crying, the heart rate may be as high as 180. If you have difficulty counting the heart rate, tap your finger or foot with each beat. Be patient. Counting a newborn's heart rate for a minute takes PRACTICE. After you have counted for a minute, move to each of the four areas of the heart to listen for a heart murmur or heart irregularities.

Respirations

During inspirations observe the bilateral expansion of the barrel-shaped chest. Observe for symmetry and retractions.

Left: Normal nares vs. nasal flaring Right:Intracostal retractions

Observe for signs of respiratory distress which include: nasal flaring, intercostal retractions between the ribs, or a grunting or a singing noise with inspiration.

Count the respiratory rate for a full minute. You may want to observe the rise and fall of the abdomen as you count the respirations. The respiratory rate is irregular due to the immature neurological system. The best position to listen is the opposite side from the heart. The normal rate is 30 to 60 breaths per minute. A respiratory rate that is tachypneic or bradypneic two hours after delivery may indicate a problem. Listen to bilateral breath sounds from the base (bottom) of the lungs to the apex (top) of the lungs with the infant lying on his/her back. Note the presence of crackles or wheezes.

Although not a part of the vital signs, assess the abdomen. Observe the soft, dome-shaped, round abdomen which moves with respirations. Listen to the four quadrants for bowel sounds. You may now put aside your stethoscope. Usually the abdomen is not palpated.

Temperature

The axillary temperature is taken by inserting the digital thermometer under the axilla in line with the infant's arm. Hold the infant's arm firmly against the thermometer. The infant may cry. Be patient. It will be over soon.

The normal axillary temperature is 36.5 to 37.2 C. Due to wetness after birth and lack of body fat, infants are at risk for hypothermia. The infant should be uncovered for a very short period of time. The infant hat maintains body warmth. The first bath is not given until the infant has three temperatures above 36.5 C. The axillary temperature is the method of choice until age 6.

Note: The heart rate, respirations and temperature can be completed when the infant is held skin-to-skin by the mother. The stable infant does not need to return to the radiant warmer for assessments. It is always important to complete the assessments rapidly to prevent hypothermia.

Inability to maintain temperature (inadequate thermoregulation) can be the first sign of infection or sepsis for the infant. In addition to a temperature less than 36.5 C, other signs of infection may include rapid respirations and inadequate feeding. Note that infants may have a low temperature whereas adults have an elevated temperature with infection.

A more complete head-to-toe examination follows the initial rapid assessment and vital signs. It may be delayed until the mother has breastfed her infant or held the infant skin-to-skin.

Test your memory...

WEIGHT, HEAD AND CHEST CIRCUMFERENCE AND LENGTH

The weight, head and chest circumference and length are measured soon after birth. These may be delayed so that the mother and infant may bond with skin-to-skin contact.

Weight

The initial weight is measured soon after birth. Place a protective paper on the sanitized digital scale and set it to "0". The infant is placed on the scale without clothing. Keep gloved hands close to the infant to prevent a fall. Note weight in kilograms and pounds. Weigh the infant quickly to prevent heat loss, which could lead to hypothermia.

An infant born at 40 weeks gestation (normal pregnancy) and weighing >2500 grams and < 4000 grams is considered AGA or appropriate for gestational age. A small infant is SGA. A large infant is LGA. Although infants can lose up to 10% of their birth weight during the first few days, the physician should be notified if the infant loses 7% of birth weight to monitor for dehydration. The lost weight is regained within the first two weeks. Weight is obtained daily at the same time. SGA and LGA infants are at risk for hypoglycemia. Their glucose levels will be monitored closely in the first few hours after birth.

Pictures used with permission from Dr. Janelle Aby, Stanford Medical Center, Palo Alto,CA

Head Circumference (FOC or frontal occipital circumference)

A clean paper tape is used for each infant. Usually it is located in the "newborn pack" that includes hats, shampoo and comb. Measure the head circumference at the greatest diameter around the forehead (frontal area) and back of head (occiput). The average head circumference (HC) is 33-37 cm.

Microcephaly (as in the picture below) is a head smaller than 32 cm. Hydrocephalus occurs when the head is 4 cm greater than chest circumference.

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

Chest Circumference

Measure the chest circumference at the nipple line. The average is 30 to 33 cm and should be 2-3 cm LESS THAN head circumference.

  Elsevier picture (Courtesty Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA).

Length

Measure from the top of the head to the bottom of the heel. Make sure the knee is extended (and not bent). The normal length is 45 to 55 cm. (One method of measurement is to mark the top of the head and the end of the heel on the sheet and measure between the two points).

See Newborn Assessment video for a demonstration of length measurement.

Growth Chart

Head circumference, chest circumference, length and weight are plotted on a growth chart. While in the hospital, the weight is monitored each 24 hours. After discharge from the hosital, these measurements are taken at each visit to the pediatrician to monitor growth.

Click here to plot values on an interactive growth chart. Use today's date for the birth date. Length 54 cm, weight 3.9 kg and head circumference 36 cm. Choose the newborn growth chart for a girl.

A complete head-to-toe examination follows these measurements and may be delayed until the mother has had time to breastfeed her infant or hold the infant skin-to-skin.

COMPLETE HEAD-TO-TOE SKIN ASSESSMENT

The more complete head-to-toe assessment begins with observation, listening and smell. Wear gloves if the infant has not had the first bath. Inspect the naked newborn in a well-lit, warm area. Check for skin color, rashes or birthmarks. Assess for hydration.

Skin Color

The skin color should be pink. Vernix Caseosa may be present on the skin after birth and may remain in the skin folds after the first bath. Vernix is normal. Lanugo is most noticable on the shoulders, forehead and cheeks. Acrocyanosis in the first 24 to 48 hours is normal. Ruddy or dark red color may occur with prematurity or polycythemia. Palor occurs with cardiovascular problems, blood loss or infection. Cyanosis or blue or gray color of skin or lips (circumoral cyanosis) can occur with infection, hypothermia, hypoglycemia, respiratory or cardiac difficulties. Mottled skin can occur if the infant is cold. It will resolve as the infant is warmed. Jaundice or yellowing of the skin can occur in the first days. It is usually due to high bilirubin levels from hemolysis of red blood cells. A green skin color may be due to in utero release of meconium stool by the fetus before birth. Odor may indicate an intrauterine infection.

Review the flash cards to become familiar with variations of skin assessment.

SKIN ASSESSMENT TERMINOLOGY

HEAD, NECK And SHOULDER ASSESSMENT

Assessment of the head is important as it reflects an evaluation of the central nervous system. Often assessment of the newborn's head reveals minor variations from normal which are not usually of clinical significance. Because parents often focus on the head first, it is important to reassure them of the normal variations.

Molding

Assess the appearance, shape and presence of molding.  

The left picture (above) shows how the head is elongated in molding. The right picture shows the angled indentation of the sutures where the bones overlap each other. This is called overriding sutures.

The left picture shows how the sutures allow the bones of the cranium to mold or compress to facilitate movement move through the vagina. The right picture shows the infant cranium on the first day of life and 24 hours later. Infants born via c-section birth or breech birth do not have molding. The temporary cranial asymmetry returns to a normal shape by the end of the first week.

Caput succedaneum or Cephalohematoma

With the infant lying on his back, cradle the infant's head in your hands. Feel for softness or "squishiness" on one side or both sides of the head. This can either be a "caput"(A) or a cephalohematoma (B). The swelling with caput disappears by the end of the first week whereas the swelling of cephalohematoma may take six weeks. Caput can cross over suture lines whereas cephalophematoma may be confined to one cranial bone. Neither of these variations are present with a c-section birth.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

The pictures above show an infant head with a caput. The first picture shows molding of the head, caput and swelling at birth. The second picture shows pitting and bruising on the head. The third picture shows an almost normally shaped head at 24 hours after birth.

 Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

These pictures show a cephalohematoma. The infant has swelling over the right parietal bone (left). The right picture shows swelling over the left parietal bone.

Anterior and Posterior Fontanels

 While holding the head with one hand, move the "pointer finger" of the other hand to the front of the head to palpate the triangular shape of the anterior fontanel. Measure the length and the width. A rough estimate can be obtained by using the width of the finger as 1 cm and measuring the length and width in this manner. If a more exact measurement is needed, use a tape measure.

From the anterior fontanel trace your finger down the juncture of the sagittal suture and the lambdoidal suture to the posterior fontanel. This may be barely palpable. The posterior fontanel disappears at 6 weeks, whereas the anterior fontanel disappears at about 18 months. Although the anterior fontanel is described as a 5cm diamond shape, the fontanel size varies with the degree of molding. It may be difficult to palpate the fontanels if there is a great deal of molding. As the molding resolves, the fontanel size will increase. Depressed fontanels can be due to dehydration whereas bulging fontanels can be due to hemorrhage, infection or tumor. Large flat and soft fontanels could be due to hydrocephaly, hypothyroidism or malnutrition.  

Neck and Shoulders

Observe the neck. Check the movement and position of the head. Restricted movement or holding the head at an angle could be due to torticollis (wryneck) or opisthotonos. Absense of head control may be due to prematurity or Down's Syndrome.

 Use fingers from both hands to palpate simultaneously for intactness and crepitus of the clavicles. Assess range of motion of arms. One arm may also have decreased range of motion with clavicular fracture. This should be assessed with any difficult birth, particularly with shoulder dystocia.

This unhappy newborn has a right fractured clavicle probably due to a difficult birth with shoulder dystocia.

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

FACE: EYES, EARS, NOSE, AND MOUTH ASSESSMENT

Eyes

Most parents who see their infant for the first time focus on the head and the face especially the eyes as they are the most dominant facial feature of the neonate. Many of the worrisome abnormalities are transient phenomena, related to birth or immaturity of the neurological system.

• Iris color of the eyes is usually grayish-blue in caucasian infants and grayish-brown in infants of color. The final color of the individual newborn's eyes occurs as pigment is gradually deposited over the next 6 to 12 months.

Normal Eye

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• Tears are not usually produced until one-to-three months of age.
• The sclera usually have a bluish tint. Yellow sclera can indicate jaundice.
• Conjunctival hemorrhage can occur with traumatic birth. This resolves over the first week of birth.

Conjunctival Hemorrhage

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• Although the eyes appear mature, the macula, which provides central vision begins to differentiate shapes and color during the first month, but is not fully developed until eight months of age.
• Infants can have pseudostrabismus or nystagmus. This recedes by the third or fourth month as the orbital muscles mature.

Pseudostrabismus

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• The eyelids may be swollen and reddened from birth or from the erythromycin eye ointment.
• Petechiae or telangiectasias, also known as "storks bites" may occur on the eyelids or forehead and nape of neck. They are classified as vascular nevi and usually disappear by 12 months.

An attempt to open the eyelids usually meets with resistance, especially if the infant is crying or there is a bright light. To open the eyes spontaneously, hold the infant upright and gradually rotate him. If this does not work, hold the head steady with one hand while you use the "pointer finger and thumb" of the other hand to gently open the eye and look at the iris and sclera. (See picture of "Normal eye" above). Nurses do not assess the red reflex or pupillary dilation of the newborn eye.

Ears

Assess the position of each ear by drawing an invisible line across the inner and outer canthus of the eye to the insertion of the ear, not the height of the pinna.

Normal Ear

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• Low-set ears can be associated with abnormalities of the internal organs (especially kidneys), chromosomal disorders or mental retardation.

Low Set Ears in Trisomy 18

Picture used with permission Dr. David Clark Stanford Medical Center, Palo Alto, CA

• Assess for size (large, small) and stiffness of the ear lobe. In mature infants, when the ear lobe is lightly bent forward and let go, it will quickly return to the previous shape. Premature infants often have a lack of cartilage, so their ears may be less resilient with this assessment.

Preauricular Ear Tag

Picture used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• A preauricular ear tag is an extra piece of material on outside of ear. May be removed or not. Assess for renal abnormalities as the ears and kidneys form at the same time embryologically.
• Assess for response to sound while in the quiet alert state. Most hospitals complete a hearing test on the infant prior to discharge from the hospital. If the infant does not pass the test, a referral is made.

Nose

Observe for flaring (enlargement of the nostrils), a sign of respiratory distress. Newborns may do this occasionally. They may also do this more frequently after birth. If flaring occurs with an elevated respiratory rate, retractions and/or grunting, notify the physician.

Left:Normal nares Right:Flared nostrils

Malformations of the nose or copious drainage may occur with choanal atresia or congential syphillis.

Mouth

Assess the outside and inside of the mouth. The color of the lips, gums and tongue should be red.

• Inspect the lips for abnormalities (cleft lip,circumoral palor or cyanosis,or asymmetrical movement of the lips).
• Don a glove to palpate the upper part of the mouth for an intact soft and hard palate. A cleft palate may occur with a cleft lip or separately. Both affect feeding efficiency by breast or bottle and need surgical repair.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• Check the strength of the infant's suck reflex.
• Check the gums or palate for nodules that look like grains of rice. These are called Epstein Pearls or Bohn's Nodules and are hereditary. The infant may also have teeth. These are normal variations that are not treated.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

• Assess the tongue for attachment, mobility and size. A tongue which has a short frenulum may cause the infant to have difficulty latching and sucking on the breast. (See article: http://pediatrics.aappublications.org/cgi/content/full/110/5/e63). Sometimes the frenulum stretches. Sometimes it needs to be clipped by a pediatrician or a surgeon to increase movement.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

HEART, RESPIRATORY, ABDOMEN ASSESSMENT

Heart and Respiratory

The heart and respiratory assessment were described under the initial exam and vital signs (slide 3).

• It is best to do these exams when the infant is quiet. If the infant is crying, you may insert a clean gloved finger into the infant's mouth to initiate sucking. This may quiet the infant while listening to the heart and lung sounds and counting the rates. If this does not work, you may swaddle the infant in a blanket and cradle or rock it in your arms as this will soothe him/her. Don't forget to wipe the stethoscope with an alcohol wipe between infants. Warming the bell will prevent a startle reflex from the infant.
• Observe the chest for evenness of respirations. Respirations are diaphragmatic, so that abdominal and chest movement are synchronous.
• Observe for intercostal and substernal retractions or see-saw respirations which indicate respiratory distress.

Supernumerary Nipple Under Infant's Left Nipple

Pictures by Janelle Aby, MD, Stanford Medical School

• Assess for nipple/breast tissue for size and symmetry. Breast buds are the amount of areola raised off the chest. This tissue measures about 6mm in the term infant, smaller in the premature infant. Fuller areola and greater breast tissue occurs in full term infants. Additional nipples or supernumerary nipples may be located along the nipple line. These findings are noted but no intervention taken.
• Palpate the brachial artery on the inside of each upper arm. This is the pulse that is palpated during resuscitation.
• Auscultate heart sounds. Because the heart rate of the infant is rapid, it takes a lot of practice. Be patient. You will learn!
• Count the heart rate first for a full minute.
• If you are musical, set a metronome at a rate of 140 or 150 and count the rate for a full minute.
• Then listen to one element at a time, 1st heart sound then the 2nd heart sound. Do you hear a single sound or two sounds with each sound (split heart sound).
• Then listen to the systolic interval and diastolic interval. Is there a murmur? Systolic murmurs are not uncommon in infants. They are usually due to shunting through the patent ductus arteriosus (PDA) and disappear in a few days. A diastolic murmur is an unusual finding. If the infant is symptomatic (cyanotic, rapid respirations, poor feeding), the physician may order blood pressures on all four extremities to rule out coarctation of the aorta (COA). Click here to listen to the heart rate at each of the four locations of this infant's heart.
• Auscultate breath sounds. Auscultate front and sides, then the back. Sounds should be clear bilaterally. Click here for normal breath sounds. Click here to listen to tachypnea. Click again.
• After a c-section, the infant may have some crackles in the bases. Crying and movement will help to clear the lungs. Click here to listen to crackles in the lungs. If the crackles are combined with nasal flaring, retractions and grunting, the infant may be transported to the NICU for closer observation.

Abdomen

• Observe the abdomen for symmetry of shape and movement. The abdomen is rounded and soft. It may be mildly distended if overfed.Marked distension can be due to gastrointestinal malformations.
• Auscultate the abomen. If the infant has had a bowel movement and there is no distension, it is not necessary to ausculate all four quadrants. Bowel sounds become active 1-2 hours after birth.
• Palpate to determine the softness of the abdomen. The pediatrician or nurse practitioner will palpate for the liver, spleen or kidneys..Palpate the femoral pulses. This is a difficult part of the examination, so be patient. Place the tip of your index fingers in the groins. It is helpful to remember from anatomy where the femoral artery ought to be! Slowly move the position of the tips of your fingers until you feel the pulse. Compare the strength of the pulse on each side at the same time. A weak/thready pulse may suggest coarctation of the aorta (COA). Note that if your pressure is too light or too heavy, you may not feel the pulse! In rare cases, congenital defects of the abdominal wall occur (see side panel).

Umbilical Cord

After birth, the cord is cut and clamped. Note any redness, discharge or odor which may indicate an infection. If these symptoms are present, the physician will need to be notified to determine if laboratory tests are needed.

• The umbilical cord is whitish gray, gelatinous, and odorless. The two arteries and one vein can be viewed soon after birth.
• The pulse can be felt from the umbilical cord right after birth.
• The cord clamp remains in place for 24 hours, at which time the cord is dry, shriveled and black.
• See right sidebar for teaching instructions to parents.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

MALE AND FEMALE GENITALIA, FEMORAL PULSE ASSESSMENT

GENITOURINARY(GU) ASSESSMENT: URINE AND STOOLS

Unfasten the diaper. Always cover the penis with the diaper or you may be surprised with a shower.

Female Genitalia

The clitoris is usually edemetous. The labia majora usually covers the labia minora. In premature infants, the labia minora is prominant. In the picture below the white material is vernix caseosa. The infant may have pseudomenstruation caused by maternal hormones. This can cause a mucoid (left picture), or pink or blood-tinged discharge (diaper, right picture). There can be a vaginal skin tag. The black liquid (left picture) is the meconium, or the first stool and should be passed in the first 24-48 hours after birth. Meconium lasts 24 hours and is sticky and thick. It indicates that the anus is patent.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

 Male Genitalia

Observe the penis and scrotum. The picture on the left shows a normal uncircumcised male genitalia.

• The meatal opening is round and on the tip of the glans penis.
• The scrotum has rugae or wrinkles. If the infant is premature, there may be fewer rugae and the testicles may be undescended. If the scrotum has deep rugae and is more pendulous, the infant is more matue. The color of the scrotum varies from pink to darker brown depending on skin color and maternal hormones.
• With your thumb and index finger, palpate for the presence of the two hard, round testicles, one on each side of the scrotum. If you can't feel the testicle, put your thumb higher on the groin over the inguinal canal and "milk" it toward the scrotum, letting it slide between your index finger and thumb. Undescended testicles occur in 3-4% of term infants.
• The scrotum in the middle picture is a hydrocele. The right picture shows a hypospadias.
• The cremasteric reflex occurs when the infant is cold and the testes retract.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

Urine and stools

The first stool and urine should occur within the first 24 hours of birth. Passage of the stool usually indicates a patent anus.

• Meconium is the first stool (below: left picture). It is thick and difficult to wipe off.
• By day 4, the stool changes to a transition stool (below: middle picture). The color is green/yellow/black and seedy in the exclusively breastfed infant.
• After the fifth day, the stool is bright yellow, runny and seedy (below: right picture). Often the parents mistake the breastfed stool for diarrhea. The stool of the breastfed infant is not odorous until the infant begins solid foods at 6 months. Formula fed stool is darker yellow and pasty and malodorous.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

Diapers are very absorbent, so it is often difficult to tell if they are wet. Urate crystals are a frequent intermittent finding during the first week. It is a normal variation and needs no lab analysis.

During the first 24 hours, one wet diaper and one stooled diaper are expected. During the second 24 hours, the infant should have a minimum of 2 wet and 2 stooled diapers. After day 5, the infant should have at least six wet diapers and 2-3 stooled diapers.

At this time you may want to put a clean diaper on the infant. Remember that the designer part of the diaper is in the front and the fastening tabs are in the back. The tabs are brought to the front of the diaper can be reapplied many times. Don't forget to take off the covering over the tabs before you try to fasten them. Much easier than using cloth diapers and safety pins, but not as eco-friendly!

EXTREMITIES

REFLEXES: ROOTING, SWALLOWING, MORO, TONIC NECK, PALMAR, PLANTAR, BABINSKI, STEPPING, GALANT

Extremities

Make a general check of the extremities. Note color, symmetrical, range of motion and flexion of legs and arms.

• Count toes and fingers and note absence, excess or webbing of fingers or toes.

 Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

•  Note acrocyanosis of feet or hands.

• Soles of the feet in term infants are well lined (or wrinkled) over two thirds of the foot.
• Note the palmar creases. The infant should have two palmar creases which go across the palm of the hand. If only one is found, the physician should be informed.

• Check the infant for flexion of both arms and legs. An infant who is floppy and does not hold extremities close to the body may hypotonia and need additional assessment by the physician. This infant may also have difficulty feeding due to weakenned rooting and suck reflexes. A term infant should be able to hold its head up for a short period of time.
• Check the hips for dislocation. Use the Ortolani and Barlow's method to assess. The newborn video has a very good demonstration of how this is done.

Reflexes

Assessment of the reflexes determines the maturity of the neurological system. See your maternity textbook, Lowdermilk & Perry (2007), p. 653-655. Many of these reflexes are no longer evident by 4 to 6 months of age. The reflexes include the palmar grasp, sucking, rooting, swallowing, tonic neck or "fencing", moro, stepping, crawling, babinski and plantar grasp. As you become more proficient in your exam you can incorporate these reflexes in other parts of your exam.

While assessing the arms, put a finger in each of the infant's palms. The infant's fingers will curl around yours. Show the parents about their amazing newborn at the same time you do the assessment of the palmar or grasp reflex.

The sucking and swallowing reflexes are present in the term infant. They may not be present in the preterm infant. Feeding by breast or bottle cannot be initiated until the suck and swallow reflexes are present in the preterm infant.

 The rooting reflex is elicited by stroking the cheek, lip or corner of the mouth. The infant turns the head toward the stimulus and opens the mouth. If close to the breast, the infant takes the nipple and begins sucking. Watch the video on how to elicit the rooting reflex.

Hold the infant in a semi-sitting position and allow the head and trunk to fall backward to an angle of at least 30 degrees. The arms will symmetrically abduct and extend while fanning the fingers to form a C with thumb and forefinger. Legs follow a similar pattern. A tremor may be seen. (The infant is not shivering). This is the moro reflex. While you have done other parts of the exam, you may have already noticed the infant throw his/her arms out in response to jarring the the bed or a loud laugh. This is sufficient to assess the reflex.

Moro Reflex (Elsevier)

Watch two videos on how parents have elicited the Moro Reflex:

The tonic neck or fencing reflex is seen by turning the head gently to one side while the infant is falling asleep or sleeping. With the face looking to the left, the left arm and the left leg will be extended. The right arm and leg will be flexed. Turn the face to the right and the right leg and arm will be extended and the left arm and leg will be flexed. Watch the short video about what the tonic neck reflex looks like.

The plantar reflex is elicited by pressing your finger at the base of the toes. The toes curl around your fingers.

Babinski reflex is elicited by moving your finger on the side of the foot from the heal across the the ball of the foot. A positive babinski is normal in newborns when all toes hyperextend with dorsiflexion of the big toe. Click here to view a babinski reflex.

Babinski Reflex (Elsevier)

The stepping reflex can be elicited by holding the infant vertically, allowing one foot to touch the table and then the other. Click here to view a video of the stepping reflex.

Stepping Reflex (Elsevier)

Galant or trunk incurvation is seen when the infant is placed prone. Run the finger down the back lateral to the spine. The trunk will swing toward the stimulted side. Watch the movie to learn how to elicit the Galant reflex.

For additional video clips of the reflexes please click here.

BACK, SPINE, ANUS

Support the infant's head when you turn it from back to stomach. Put one hand behind the head and slip the other hand/arm under the infant's chin and stomach and turn over. Let the infant lie on his/her stomach (with legs pulled up). Use the same method to turn the infant from front to back.

The infant may be able to lift the head momentarily.

Inspect the spine and shoulders for straightness and flexibility. Check the base of the spine for a pigmented nevus with a tuft of hair. The infant may have a pilonidal dimple, a small dimple at the base of the spine without connection to the spinal cord. This is often associated with spina bifida occulta.

Pictures used with permission Dr. Janelle Aby, Stanford Medical School, Palo Alto, CA

This is a good time to elicit the Galant reflex and check for Mongolian or Slate-grey spots. Check that there is one anus. Passage of a meconium stool either in utero or within the first 24 hours of birth signifies a patent anus. Rectal temperature is no longer used to check for anal patency. When you have completed the exam, turn the infant to the back, make sure the diaper is clean and fastened. Redress the infant. This is a good time to ask the parents if they want you to show them how to wrap the baby. First time parents and the father are usually interested in this education. Review parental education on handling and sleep patterns (see sidebar).

CONGRATULATIONS!

YOU HAVE COMPLETED THE NEWBORN ASSESSMENT eLEARNING MODULE!

GO TO THE ASU ONLINE LEARNING RESOURCE CENTER TO WATCH THE FOLLOWING NEWBORN ASSESSMENT Videos.

Newborn Physical Assessment Video

Gestational Age Assessment Video