Posture

Flexed extremities resisst extension, return quickly to

flexed stsate. Hands usually clenched. Movements
ymmetric. Slight tremors on crying.
Temp. 36.5-37.3 C ( 97.7-99.1 F) axillary (preferred) Decreased ( cold environment, hypoglycemia, infection,
cns problem)
36.5-37.7 C (97.7-99.8) rectal
Increased (infection, environment too warm)
Decreased: institute warming measures, chk in 30
mins. Chk blood glucose level
Increased: remove excessive clothing. Check for
dehydration

Decreased or increased: loof for sx of infection. Chk

raiant warmer or incubator temp setting. Chk
thermometer for accuracy if skin is warm or cool to
touch. Report abnormal valus to md

Note lcoation of murmurs. Refer abnormal rates,

Pulses- HR 120-160 bpm( 100 bpm sleeping, 180
crying)
PMI at 3rd-4th interconstal spce, slightly to oleft of
midclavicular line
Tachycardia >160 bpm,(respiratory problems, anemia,
rhythms, sounds pulses
infection, cardiac conditions)
Brady cardia < 80 bpm ( asphyxia, Increased intracranial
pressure, heart block) PMI to right ( dextocardia,
pneumothorax)

Murmurs ( functional or congenital heart defects)

Arrythmias, absent or unequal pulses (coarctation of Mild variations need continued monitoring, usually
aorta) clear in early hrs aftr birth. If persistent or more than
mild. Suction, give O2, cal md, initiate more intensive
care

Respirations
30-60 breaths/min (average 40-49 breaths/min)
Respirations irregular, shallow unlabored. Chest
movements symmetric.
Breath sounds present & clear bilaterally
Tachypnea esp after 1st hr (respiratory distress) slow
resp- (maternal meds) Nasal flaring, frunting
(resp.distress synd) gasping(resp depression) periods of
apnea > 20 sec or w/ chge in hr or color (resp.
depression, sepsis, cold stress) aymmetry or decreased
chest expansion (psumothorax) Intercostal, xiphoid,
supraclavicular retrations or seesaw
respirations(respiratory distress) moist coarse breath
sounds (crackles, rhohnchi, fluid in lungs) bowel sounds
in chest (diaphragmatic hernia)

Refer anormal blood pressure . prepare for intensive

care if very low