10.02 Newborn Physical Exam

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Overview

  1. These are the first physical assessments – establishing a baseline is important!
  2. Note ALL abnormalities

Nursing Points

General

  1. Imperative that we maintain temp stability – keep baby warm!
  2. Observe, then complete least disruptive assessments, progressing to most disruptive
  1. ie: Auscultate first
  1. Intrauterine – extrauterine transition period
    1. Going from the inside world to the outside world is traumatic for them
    2. First 6-8 hours of life outside of the womb
    3. 3 phases
      1. Reactivity
        1. Most alert-best feeding time
        2. First hour
      2. Decreased responsiveness
        1. Sleepy
        2. Second hour
      3. Reactivity
        1. Second reactivity
        2. Hour 2-6
        3. Alert

Assessment

  1. General observations
    1. Flexed posture
    2. Palpable pulses
    3. Spine, trachea, head, nose midline
    4. Coordinated movements
    5. Count extremities, fingers, toes
    6. Check for anus and urinary meatus on penis if male
    7. Check for hip dysplasia
      1. Ortolani maneuver-rotate thighs outward and feel (no click)
  2. Vital signs
    1. Assess as much as possible while sleeping
    2. BP not routinely assessed in newborn patients
    3. Some newborns may present with slight / subtle tremors
      1. Can be normal, can be due to drugs withdrawal, hypocalcemia, hypoglycemia
    4. Listen to apical pulse for 1 full min
      1. 120-160 BP resting
      2. Might vary if in a deep sleep of crying
    5. Listen to respirations for 1 full min
      1. 30-60 RR
    6. Axillary temp
      1. 97.8-99F
  3. Head
    1. Measure head, weight, length
    2. Fontanels
  4. Eyes
    1. EOM’s weak; may be cross or have disconjugate gaze
  5. Ears
    1. No pits or skin tags
  6. Mouth
    1. Look in mouth for signs of Candida albicans (thrush)
      1. White and patchy tongue
      2. Potentially painful
      3. Do not come off with wiping
    2. Check for intact palate
  7. Chest
    1. Assess for clavicular fractures from birth
    2. Diaphragmatic respirations may be observed
    3. Breast tissue swelling might be observed
      May note secretions from nipple
  8. Umbilical cord
    1. Assess for 2 arteries, 1 vein
      1. Mnemonic: AVA-2 arteries and 1 vein
        1. Notify if abnormal
    2. Assess for meconium staining on cord
  9. Genitalia
    1. Female-blood stained discharge may be present due to sudden decrease of estrogen
    2. Female- might be swollen, prominent majora
    3. Male-hydrocele-excess fluid in the sac
    4. Hypospadius- Urethra in under the penis
  10. Skin
    1. Document skin abnormalities thoroughly
    2. Assess for any skin trauma from labor and delivery, especially if assisted
    3. Should have creases on hands and feet
      1. More creases equals further in gestation
  11. Possible skin findings in a newborn:
    1. Erythema Toxicum
      1. Normal newborn rash
      2. Red spots that pop up and move to different spots
    2. Acrocyanosis
      1. Blue extremities
      2. Normal for first few days
    3. Lanugo
      1. Fine body hair
    4. Harlequin Sign
      1. Red/pink on one half of body
      2. Other half normal or pallor
      3. Indicative of cardiac issues or sepsis
    5. Milia
      1. Small white sebaceous glands
      2. Typically noted on face
    6. Vernix caseosa
      1. White cheese-looking substance
      2. Preterm: covered
      3. Term: typically only in folds
      4. Postterm: absent
    7. Stork bites
      1. Telangiectatic nevi
      2. Nevus simplex
      3. Nape of neck, nose, eyelids
      4. Dark red – pale pink
    8. Port-wine stain
      1.  Nevus vasculosus
      2. Typically on face (Gorbatschow has one)
      3. Flat
      4. Red – purple
      5. Technically a capillary angioma below skin
    9. Strawberries
      1. Nevus vasculosus
      2. On face / head
      3. Raised
      4. Capillary hemangioma
    10. Mongolian spots
      1. On back, bottom
      2. Black – blue
      3. Flat, wavy borders and irregular shape
      4. More common in various races (African, Asian, Native American)

Therapeutic Management

  1. Keep the baby warm
  2. Position baby on blanket or chux pad when weighing

Nursing Concepts

  1. Keep the baby warm
  2. Position baby on blanket or chux pad when weighing

Patient Education

  1. What we are looking at and for
  2. How often they should expect vitals to be taken

Reference Links

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Video Transcript

In this lesson I’m going to help you understand how to perform a newborn physical exam to put it into practice.
So just a few general points to start with. It is absolutely imperative that we maintain temperature stability so please, please, please keep the baby warm! When babies get cold they can have cold stress and really spiral out of control in the wrong direction. It can lead to low blood sugars and respiratory problem so keep them warm! In these first few hours the baby is going through an intrauterine to extrauterine transition period. So some hospitals have what is called transition nurses. That is my main role at the hospital that I work at. I go to all the deliveries and provide immediate care of the newborn through their transition time and ensure they are stable before moving to the postpartum floor. So this time period is crazy for them they are going from the inside world to the outside world and just think about how traumatic this is for them! There are 3 phases known as reactivity, decreased responsiveness, and second reactivity that occur during these first few hours of transition. So reactivity is the first hour and is when they are the most alert so this is the best time to initiate feeding. Remember that, it will probably be a test question! This is followed by decreased responsiveness for the second hour and the baby is more sleepy. Then we have reactivity again which is hour 2 to 6 and the baby is alert again.
These are just some general observations that you will start with on assessment. The baby should be in a flexed posture. This shows us the baby has good tone. The body should be symmetrical with the spine, trachea, head, nose midline. Sometimes the way the baby has been positioned or their delivery could cause some asymmetry. Like a nose that is smooshed or ear bent funny. As long as it appears as this and that it is not a deformity it is ok. Movements should be coordinated and this means they can equally move their arms an legs. Count the fingers and toes. Sometimes there is an extra digit. They might have a bone or be boneless and dangle. So every nurse has something that just sort of weirds them out or that they have trouble doing. For some this might be suctioning or sputum, well I’ll be honest an extra digit, especially boneless is my least favorite! Believe me I love babies all babies but those extra dangling digit is something I really don’t prefer but of course keep a straight face and try not to stare at it! I had a baby born the other day with a full extra thumb. It was one bone that went up and branched into two. Instead of the baby bending the thumb towards the other fingers the two thumbs pinched together like a crab claw. It was the first time I had seen something like this. That baby will have no problem with her pincer grasp and picking up cheerios for sure! Vital signs will be assessed and should be attempted when the infant is quiet. Blood pressure is not routinely assessed unless in the NICU or there is a suspected problem. It is important that you listen to the apical pulse and respiratory rate for a full minute. The expected heart rate is 120-160 and respiratory rate is 30-60. Of course deep sleep or crying could alter this a bit. You might observe slight tremors and this is mostly normal but can be due to drugs withdrawal, hypoglycemia, and rarely hypocalcemia so if the baby has tremors there might be some further assessment needed like blood sugar and also you can refer to the neonatal withdrawal lesson for more on that.

Now we are moving to our head to toe assessment.The head is important to assess and you want to ensure the fontanels or that soft spot, is not bulging and is flat. You will also probably observe some caput and molding from coming through the birth canal. So this is just some swelling and edema at the head that will resolve. The muscles of the eyes are weak and have to get strong so you might notice the eyes to cross. Parents will probably notice this and point it out with concern. Check the ears for symmetry and any skin tags or ear pits. Ear pits are little holes where the ear connects. It is like a pin point hold. So fun fact if there is something wrong with the ears they will usually do a kidney ultrasound because kidneys and ears develop at the same time in utero. Ever notice that the ear sort of looks like the kidney shape? Cool, right?! The mouth should be assessed for intact lips and the palate to be intact. So just putting a gloved finger in their mouth to feel the palate. You will feel a hole if a cleft is present. Also make sure there are no teeth. Yes this happens they can be born with a soft tooth that will fall out. That might be under the category of one of my other nursing “things” that I don’t prefer to see! They just aren’t supposed to be there! But the good news is they will usually fall out and cause no problem for feeding. We are now at the chest so check for symmetry and equal rise of the chest and also check the clavicles to ensure there has not been a fracture from birth. The breast tissue might be enlarged and you may note secretions from nipples. Those babies get all those hormones from mom too so they have to circulate them through and out of their system. Ok now moving down to the umbilical cord. We need to make sure there are 2 arteries and 1 vein. Remember the mnemonic AVA. two arteries and one vein. Alright let’s look at some more additional assessment pieces.

We are now at the genitalia. The female genitalia might show some swelling and usually has a prominent majora and you might even see blood stained discharge and this is normal and just because of those hormones again, but can be scary for parents to see. I try to tell them this might happen before they are discharged so they aren’t alarmed at home if it happens. The male urethra should be noted to be midline and testicles present in the sac. Ok with the anus we need to ensure it is checked and patent. So if it is not then this baby needs surgery to open it. One time I had a baby and the anus appeared to be there. All of the markings were there. The physician did her exam and noted the same thing. Well let me tell you what happened! That night the night shift nurse put the baby on its belly on the scale to get the weight. The positioning of the baby made her realize it was not patent. The baby had been feeding by bottle for several feedings so the belly was filling up but had nowhere to go. The baby had to have immediate surgery! So I tell you this so you will learn what I learned. You have to really spread the skin and ensure it is patent!The babies hips should also be checked for hip dysplasia. This is called ortolani’s maneuver. You will rotate thighs outward and feel for a click. You want to feel no click. During all of this assessment you will be looking at the skin for any birthmarks, brusinging, lacerations and documenting it. There are a few normal skin conditions of the newborn and some skin abnormalities. Refer to the outline for more information on those but I wanted to briefly mention 3 big ones. Acrocyanosis which is the blue hands or feet that will pink up within a few days. Milia which are clogged sebaceous glands usually on the nose and this appears as white dots and last is erythema toxicum which is just newborn rash. For some reason most babies get reddened spots that pop up and move around their body. It is very normal. We think of it as a reaction to the outside world!
So what are the big management and education items? First you can probably guess I’m going to tell you that the baby needs to keep warm. So provide warmth during assessment and position the baby on blanket or chucks pad when weighing so they don’t get cold from touching the cold surface. We also just want to let parents know what we are doing and what we are looking for. Sometimes when you are really taking time to look at something closer it can make them panic so just let them know what is going on.

Human development and thermoregulation are our concepts. We need to keep the baby warm and we are assessing the development of the baby.
The key points to remember are that the newborn physical exam is a thorough head to toe assessment. You must keep the baby warm during this and note any abnormalities or concerns. Obtaining weights and measurements of the head, chest, and abdomen will also be part of this assessment.
Make sure you check out the resources attached to this lesson review the abnormalities that you are looking for on the assessment. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 10

The nurse is assessing a newborn’s reflexes who was born 36 hours ago. Which of the following findings is the MOST concerning?

  • Question 2 of 10

A nurse is performing a newborn assessment and suspects hip dysplasia. Which test finding would support this diagnosis?

  • Question 3 of 10

A nurse is performing a newborn assessment on a preterm infant. Which assessment findings should be expected? Select all that apply.

  • Question 4 of 10

A nurse received shift report on 4 newborn infants. Which infant should be seen first?

  • Question 5 of 10

A nurse working in the newborn nursery is caring for an infant who was born 3 hours ago. The infant’s axillary temperature is 97.0F and the nurse notes that newborn’s respiratory rate is 60/minute. Which action of the nurse is most appropriate?

  • Question 6 of 10

The nurse is caring for a 41-week baby that was just delivered. The nurse must assess the Apgar score. Which the following is most accurate regarding this scoring?

  • Question 7 of 10

A nurse is teaching a new mother about the best ways to be successful with breastfeeding. Which of the following are key factors in breastfeeding success? Select all that apply.

  • Question 8 of 10

The nurse is working in labor and delivery when a mother delivers a 39-week baby. Which of the following finding is the LEAST concerning at this time?

  • Question 9 of 10

A 1-week-old newborn has been admitted for sepsis. The nurse knows that which of the following things are the most important to monitor? Select all that apply.

  • Question 10 of 10

The nurse is working in labor and delivery with a mother who just vaginally delivered a baby boy after 19 hours of labor moments ago. Which of the following is NOT a priority intervention that will help with the newborn’s physiological needs at this time? Select all that apply.

Module 0 – OB Course Introduction

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