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ASSESSMENT
ALICIA A. STONE RN,MS,FNP
ASSISTANT PROFESSOR OF
NURSING
MOLLOY COLLEGE
Everyone is
kneaded out of
the same
dough
but not baked
in the same
oven. ~Yiddish
Proverb
Nursing Objectives
Education
Fetus to Newborn:
Respiratory Changes
Initiation of respirations
Chemical
surfactant reduces surface tension 34-36wks
decrease in oxygen concentration
Thermal
sudden chilling of moist infant
Mechanical
compression of fetal chest during delivery
normal handling
Apgar Scoring
Neurologic Adaptation:
Thermoregulation
Radiation
Evaporation
Conduction
Nonshivering thermogenesis
The distribution of brown adipose tissue (brown fat)
Effects of Cold Stress
1) Metabolic Rate: leads to use of glucose and
production of Surfactant. This can lead to
hypoglycemia and respiratory distress.
2) Non-Shivering Thermogenesis-metabolism of
Brown fat. This leads to increased production of
free fatty acids, which leads to metabolic
acidosis and jaundice.
3) Vasoconstriction: leads to pale, mottled skin
and shut down of pulmonary vessels, which leads
to fetal circulation patterns.
Bonding
Vital signs
Measurements
Gestational Age
Medications
Glucose levels
Temperature
stabilization.
What is a
successful
transition???
General Survey
Appearance
Symmetry, any
obvious deformities,
size, smell, muscle
tone, sex, posture
Behavior
Crying, lethargic,
responsive, reflexes,
jittery
Measurements
Normal Weight
2500-4000gms
5 ½lbs. – 8lbs, 13 oz.
(AGA-appropriate for gestational
age)
Below normal (SGA- small for
gestational age)- <10%
Above normal (LGA-large for
gestational age)- >90%
Normal Length- 18-22” or 48-52 cm.
Head circumference- 13-14” or 32-36 cm.
(measure right above eyebrows)
Chest circumference- 12-13” or 30-34cm
(measure at nipple line)
Vital Signs
Erythromycin Ointment
FONTANELLES
Bulge – IICP
Depressed –
dehydration
Molding
Overriding
sutures.
Resolve quickly
Caput Succedaneum
Bleeding
between the
cranial bone and
the periosteum in
periosteal space.
Does not cross
suture lines
What will happen
when it starts to
resolve?
SKIN
Reddish in color,
smooth, puffy.
Edema
Turgor
Cord
Nails
Acrocyanosis
Mottling
Jaundice
PHYSIOLOGIC JAUNDICE
Hyperbilirubinemia
not associated with
hemolytic disease or
other pathology in
the newborn.
Jaundice that
appears in full term
newborns 24 hours
after birth and peaks
at 72 hours. Bilirubin
may reach 6 to 10
mg/dl and resolve in
5 to 7 days.
Vernix
Milia
Rashes/Marks
- Erythema Toxicum (Newborn Rash)
- Forcep marks
- Mongolian spots
- Birthmarks:
Port wine stain
Stork bite/Nevi
Strawberry mark
Café au lait
- Petechiae
Erythema Toxicum
Mongolian spot
Forcep mark
Port wine stain
Strawberry hemangioma
Eyes
Check color, red reflex.
Subconjunctival Hemorrhage
From birth trauma
Pinna top on
horizontal line
with outer
canthus of eye
Loud noise elicits
Startle Reflex
Flexible pinna
with cartilage
present
Nose
EXPECTED FINDINGS
Nostrils patent bilaterally
Obligate nose breathers
No nasal discharge
COMMON VARIATIONS
Sneezes to clear nostrils
Bridge appears absent
Thin white nasal mucus discharge
Signs of potential distress or deviations
from expected findings
Malformation
Nasal flaring beyond first few moments after
birth
MOUTH AND THROAT
Mucosa moist
Palate high arched
Well developed fat
pads bilateral cheeks
Sucking, rooting, gag,
and extrusion reflex.
Epstein’s pearls, thrush,
supernumerary teeth,
cleft palate
Cleft lip and palate
CHEST
Expected findings
Evident xiphoid process
Equal anteroposterior and
lateral diameter
Bilateral synchronous chest
movement
Symmetrical nipples
Common variations
"Witch's milk"
Enlarged breasts
Accessory nipples
Apical Pulse, check for
retractions, grunting
ABDOMEN
Expected Findings
Dome-shaped abdomen
Abdominal respirations
Soft to palpation
Well formed umbilical cord
Three vessels in cord
Cord dry at base
Liver palpable 2 - 3 cms below right
costal margin
Bilaterally equal femoral pulses
Bowel sounds auscultated within two
hours of birth
Voiding within 24 hours of birth
Meconium within 24 - 48 hours of birth
GENITALIA
FEMALE
Edematous labia and clitoris
Labia majora are larger and
surrounding labia minora
Vernix between labia
MALE
Urinary meatus at tip of glans penis
Palpable testes in scrotum
Large, edematous, pendulous
scrotum, with rugae
Smegma beneath prepuce
Stream adequate on voiding
EXTREMITIES
Maintains posture of
flexion
Equal and bilateral
movement and tone
Full range of motion
all joints
Ten fingers and ten
toes
Legs appear
bowed
Feet appear flat
Palmar and sole
creases evident
POLYDACTYLY
Ortolani’s
manuver
Unequal leg
length
Asymmetrical skin
creases posterior
thigh
CLUB FOOT
Talipes
Equinovarus
When the foot
turns inward and
downward
Check for normal
positioning and
whether it
corrects easily.
May be
positional.
NEUROMUSCULAR SYSTEM
Expected findings
Maintains position of flexion
When prone, turns head side to side
Holds head and back in horizontal plane
when held prone
Ability to hold head momentarily erect
Moro reflex
Signs of potential distress or deviations
from expected findings
Hypotonia
Quivering
Limp extremities or straightening of extremities
Clonic jerking
Paralysis
BEHAVIORAL
Suctioning
Positioning
Wrapping
Holding
Circumcision
Care
Newborn Testing
PKU,T4
Hearing
PARENT EDUCATION
Axillary temp
Bathing
Care of nails
Diapering
Feeding
Health care
provider visits
When to call for
immediate
attention.