1. NUR 134 NEO114 M. Johnston, RN-BC, M.Ed. OB Clinical Instructor NSCC
Neonatal Assessment
NUR 134 NEO114
M. Johnston, RN-BC, M.Ed.
OB Clinical Instructor
NSCC

2. Immediate Post Delivery
Establish Airway:
Suction with bulb syringe
Stimulate
Check Color:
Acrocyanosis
Prevent Hypothermia:
Clean, stimulate
Provide dry blankets
Check Tone:
Flexion of extremities
Suction mouth then nose, prevents infant from inhaling pharyngeal secretions by gasping as the nares are touched
Frank breech position shown

3. Drying to prevent hypothermia
Thermoregulation is balance between heat loss and heat production
Cold stress increases need for oxygen and depletes glucose stores, increases resp. rate can result in metabolic acidosis
Newborn has decrease ability to produce heat, blood vessels closer to surface
Newborns have larger body surface to body weight
Stabilize temp by placing skin to skin on mom’s abdomen and covering with warm blanket or radiant warmer
Keep head covered and ambient room temperature without drafts

4. Apgar Scoring Five categories: score 0-2 Assessed at: 1 minute
5 minutes
Rapid assessment of the newborn’s transition to extrauterine life, based on 5 physiologic states: vigorous cry, pink, HR > 100 assoc w/effective cardiopulmonary adaptation
1. Heart rate with stethoscope or palpating umb.cord
2. Resp rate based on observed movements
3. Muscle tone based on degree of flexion and extremities movement
4.Reflex Irritability based on response to bulb or catheter placed in nasopharanx
5. Color generalized: pallid, cyanotic or pink

5. Apgar Scoring Charts Evaluations are at 1 minute and 5 minutes
Score 7-10 at 5 min. WNL healthy baby (parents need to be educated about this) if<7, do expanded Apgars every 5 minutes until >7 or transfer to SCN
Score 4-6 at 5 min. moderate difficulty, close observation
Score 0-3 at 5 min. severe distress usu. Transferred to NICU
RN CNM or MD assigns the score
Doesn’t really have long term predicative value such as development and intelligence (inappropriate use by researchers)

6. Apgar Scoring Dr. Virginia Apgar
Apgar score was developed by Dr. Virginia Apgar as a means to evaluate the success of a newborn’s transition to extrauterine life; first rpesented in early 1950’s
Also used to evaluate the effectiveness of resuscitation measures
First MD to keep basic resuscitation equipment with her at all times for all deliveries
First female full professor at Columbia University for Surgeons and Physicians
Dr. Virginia Apgar
"Nobody, but nobody, is going to stop breathing on me!"

7. Weight Measure length Head circumference
Measurements done in metric and US System (grams and pounds)
Weight normal range between gms (5#8oz to 8#13 oz)
Normal to lose 5-10% of weight in first few days (usu. about 6-10 oz) cause loss of excess fluid and low fluid intake 1st few days
Length can be difficult to measure due to flexed position; crown to heel measurement cm. or in.
Head circumference (or ) cm or in. measure widest part, occipito-frontal diameter

8. Newborn Exam Warm, dry surface Adequate lighting Calm infant
First assessment is done immediately after birth (Apgars) then a comprehensive exam is completed within first 1-2 hours (RN) with normal newborn
and again within 24 hours by provider

9. Check vital signs HR range 110-160 bpm Resp rate 30-60 min
Temp – 37.5 C
Heart rate auscultate apically PMI (4th intercosta,l L of midclavicular) one full minute; may be irregular, bpm depending on activity level
Respiratory rate breathes per minute, often irregular, count for full minute when newborn quiet, periodic breathing
Observe for symmetry of chest movement
Temperature or 97.7 – Axillary

10. Normal Findings

11. Umbilical cord 3 vessels 2 arteries, 1 vein (AVA) Wharton’s jelly
Check for 3 vessel cord
2 arteries - deoxygenated blood
1 vein - oxygenated blood
Wharton’s jelly as protection
no nerve endings

12. Umbilical Cord Healing
7-10 days
Keep clean and dry
Observe for infection
Assess for hemorrhage (rare) or infection (omphalitis); stump is medium for bacterial growth
Current recommendations for cord care (AWHONN 2001) cleaning with water only
Usually cord clamp is removed at 24 hrs when drying and no longer bleeding
Assess stump and base of cord for edema, erythema, odor and drainage with each diaper change
Average cord separation is days

13. Fontanels anterior posterior Sutures
Fontanels occur at the junction at cranial bones where 2 or more sutures meet
Sutures occur in the place where 2 cranial bones meet. Newborn’s sutures should be palpable with a small space between them; may be overlapping at birth
Anterior fontanel: diamond shaped, larger than post. Closes between 12 – 18 months
Posterior fontanel: triangular shaped, closes wihtin 1st 3 months of age
Fontanels should be flat, not depressed or bulging

14. Head Molding
Molding is the shaping of the fetal head by the overlapping of cranial bones to facilitate movement through the birth canal during labor

15. Vernix Caseosa Sebaceous gland secretions
White, cheesy protective coating
Develops 3rd trimester
Decreases as fetus develops
Protects skin from drying effects of amniotic fluid
Normally found only in creases of term newborn

16. Milia sebaceous glands, usu
Milia sebaceous glands, usu. found on face, nose and chin subsides spontaneously , reassure parents
Small white spots on newborns face, nose, and chin; resemble pimples
Subside spontaneously in a few days; reassure parents

17. Telangiectatic Nevi “Stork Bites”
Telangiectatic nevi pale pink or red marks found at nape of neck, eyelids, or nose usu fair-skinned newborns
Blanch when pressed fade with time

18. Erythema Toxicum Most common face, trunk, extremities Found in 70% of
newborns
Peaks at hours
old
“Newborn rash or “fleabite dermititis” commonly occurs on chest, abdomen, back and buttocks
term newborn, 1st 3 wks of age
Thought to be inflammatory response
transient , no clinical significance, requires no treatment

19. Lanugo Fine, downy hair Develops after 20 wks gestation
Mostly disappears by 40
wks gestation

20. Meconium
Formed during fetal life from amniotic fluid (and constituents) intestinal secretions (including bilirubin) and cells shed from mucosa
1st is sterile, then contain bacteria
1st mec. usually passed between hrs old
progressive changes in stool indicate healthy functioning GI tract

21. Mongolian spots
Bluish black areas of pigmentation; may appear over any surface of body, most common on buttocks and back
Most common in infants with dark skin (African, Hispanic, Mediterranean, Asian) also found in 5-13% Caucasians
Fade gradually over months or years

22. Moro or Startle Reflex
Hold infant in semi sitting position, allow head and trunk to fall backward (with support)
Place infant on flat surface, make a loud noise
Found in term infant
This response is present at birth and may be seen until about 8 wks of age
Symmetric abduction and extension of arms, fingers fan out and form C with thumb and forefinger; cry may be elicited
Found in term infants, where the neuromuscular system is almost completely developed at birth

23. Normal Newborn Reflexes

24. Abnormal Findings

25. Neonatal Jaundice Physiological Pathologic Phototherapy
Physiologic Jaundice occurs in about half of all healthy newborns and about 80% of preterms
It arises sometime after 24 hrs after birth, yellow coloring gen. appears first on face and head then progressing towards the feet as bilirubin level rises
hyperbilirubinemia caused by excessive
Lab tests must be done for accuracy of the level, with attention to age of infant and degree of jaundice
Pathologic Jaundice clinical jaundice evident within 24 hours after birth; if left untreated, results in acute encephalopathy
Phototherapy best tmt is prevention; photometer to assure efficacy; must protect eyes, optimal skin exposure,; more at risk for fluid loss

26. Phototherapy

27. Cephalohematoma Does not cross suture line
Cephalhematoma – collection of blood between skull bone and periosteum; does NOT cross the suture line; largest 2nd or 3rd day (bleeding stops) bleeding caused from pressure against maternal bony pelvis
Caput Succedaneum – generalized edematous area of the scalp usually occipital area; extends ACROSS suture line and usually disappears in 3-4 days
Cause – sustained pressure of vertex against cervix results in compression of vessels, slow venous return increases tissue fluids and causes edema can also be caused by vacuum extraction

28. Caput Succedaneum extends across the suture line usually disappears in 3-4 days
Caput Succedaneum – generalized edematous area of the scalp usually occipital area; extends ACROSS suture line and usually disappears in 3-4 days
Cause – sustained pressure of vertex against cervix results in compression of vessels, slow venous return increases tissue fluids and causes edema can also be caused by vacuum extraction

29. Tongue-tie occurs in approx. 4% of infants
The frenulum attaches the underside of the tongue to the floor of the mouth, usually midway between the ventral surface and the tip
A very thick or prominent frenulum (tongue tied) is quite rare
presents difficulty with breastfeeding

30. Simian Crease (Single palmar crease)
Usually associated with Downs Syndrome (Trisomy 21), but can be found in normal infants
DS –combination of simian crease, short fingers, incurved little finger,, low set thumb,
Overlapping of 2nd and 3rd fingers, possibility of Trisomy 18

31. Club Foot (Talipes Equinovarus)
One of the most common congenital anomalies
Incidence varies with race and sex (1:1000 births Caucasians, Asians least likely, highest African and Polynesians)
Right affected more than left if unilateral
Bilateral about 50%
Variations in severity; may just need serial exercises and casting; orthopedic consult on day of birth

32. Sacral skin tag Pilonidal opening
Palpate entire length of the spine to determine the presence of dorsal spinal processes and any abnormal curvatures
Inspect from base of skull to coccyx, noting any skin disruptions, tufts of hair, soft or cystic masses, hemangiomas, or pilonidal dimple
May be Sx of congenital spinal or neurologic anomaly
Neural tube defects (pilonidal opening vs deep dimple)

33. Preterm Neonates SCN/NICU
Preterm or premature- born before completion of 37th week gestation
Late Preterm or Near Term –born between weeks

34. Maternal Infant Bonding
Parents share in the birth process 1st hour after critical for M/I contact, postpone everything not necessary until after 1st hour
Early maternal infant contact; WHY?
promotes successful breastfeeding
important for developing relationship with newborn
decreases postpartum depression
decreases risk for hypothermia for newborn
increases oxytocin and prolactin levels

35. Family Bonding
Promote family bonding, not just with mother but fathers/partners, siblings, grandparents
Childbirth practices and rituals of other cultures may not be congruent with standard practices associated with Anglo-American culture; be sensitive to cultural variations around birthing