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Each newborn (birth to 30 days) arrives as a unique person with the energetic
desire to grow and learn. For approximately 40 weeks, the fetus has enjoyed a
warm, comfortable uterine environment with all needs met. At birth, he or she is
totally dependent on the caretaker. Because the newborn is unable to directly
communicate his or her needs, the nurse must learn assessment skills to identify
abnormal findings and promote a healthy environment.
Infants (111 months) have few communication skills. As they grow, they can smile,
frown, point, and even say no, but it will be several years before they can
communicate well enough to provide information during a patient history. Until then,
parents, siblings, and extended family are fine sources of information. Healthy
families usually raise healthy babies, so take every opportunity to offer education
and support during your assessment.
As you assess the infant, be sure to note if her or his physical development is
appropriate for her or his age and whether she or he is performing appropriate
developmental tasks for that age. Because growth and development are so rapid
during the first year of life, even the slightest developmental delay may signal an
underlying problem and warrant further investigation.
KEY PHYSICAL CHANGES INCLUDE:
Birth weight doubles by 6 months, triples by 12 months.
Height increases by 1 inch per month for first 6 months.
Fontanels are closing.
Lumbar curve develops with a lordosis once the infant begins to walk.
Drooling and teething occur.
Primitive reflexes disappear as the neurological system matures.
GROSS MOTOR CHANGES INCLUDE:
Rolls, crawls.
Pulls self up to sit.
Begins to walk.
Achieves head control.
FINE MOTOR CHANGES INCLUDE:
Grasps objects.
Puts objects in mouth.
Holds bottle.
Plays with toes.
Develops pincer grasp.
SENSORY CHANGES INCLUDE:
Develops better vision.
Follows objects with eyes.
Responds to sounds.
COMMUNICATION CHANGES INCLUDE:
Initially cries to convey needs.
Babbles.
Laughs.
Says three to five words by 12 months.
Begins to comprehend simple directions.
Imitates sounds.
SOCIALIZATION CHANGES INCLUDE:
Identifies parents.
Develops social smile.
Is aware of strange situations.
Has increasing difficulty separating from parents.
Becomes more fearful of strangers.
Begins to develop memory.
Shows emotions.
3. CHEST CIRCUMFERENCE
Measure chest circumference.
Measure chest at nipple line.
4. ABDOMINAL CIRCUMFERENCE
Measure abdominal circumference.
Measure abdomen above the umbilicus.
5. LENGTH
Measure length.
6. WEIGHT
Weigh newborn.
Newborn weight is usually between
2500 and 4000 g (5 lb, 8 oz, and 8 lb,
13 oz).
7. TEMPERATURE
Take newborns temperature.
Axillary: 36.5 to 37.20C
hypothermia or hyperthermia.
8. PULSE
Auscultate heart rate.
Apical rate 120 to 160 BPM.
Rate increases with crying and
decreases with sleep.
9. RESPIRATIONS
Take newborns respirations.
30 to 60 breaths a minute; irregular.
Anesthesia during labor and delivery can
affect respirations.
10. BLOOD PRESSURE
Take newborns BP.
Systolic: 50 to 75 mm Hg.
Diastolic: 30 to 45 mm Hg.
Crying and moving increase systolic
pressure.
11. INTEGUMENTARY
Skin
Inspect skin, note, color, lesions.
Skin may be red, smooth, edematous,
mottled (cutis marmorata).
Hands and feet may be cyanotic
(acrocyanosis).
Physiological jaundice occurs after 24
hours.
Color may change with position
(harlequin sign).
Cheesy substance (vernix caseosa)
decreases as babys gestational age
increases to term.
Desquamation (peeling), ecchymosis,
and petechiae may occur from trauma
during delivery.
Milia (white papules) may occur on
face.
Miliaria or audamina (papules or
vesicles on face) are caused by
blocked sweat ducts.
Mongolian spots (bluish discoloration
in sacral area) are commonly seen in
African, Asian, Latin, and Native
American babies.
Telangiectatic nevi.
Flat hemangiomas (stork bites) may
be present at nape of neck.
Hair
Inspect hair, and note distribution.
Some lanugo is normal.
Nails
Inspect neonates nails.
12. HEENT
Head/Face
Inspect head and fontanels.
Gently palpate fontanels.
Inspect facial features and
movements.
Molding in birth canal may cause
asymmetry of face and skull and
should resolve within 1 week.
Anterior fontanel: Diamond shaped,
2.5 to 4 cm.
Posterior fontanel: Triangle shaped,
0.5 to 1 cm.
Soft and flat.
Symmetrical facial movements.
Neck
Inspect and palpate the neck.
Test tonic neck reflex.
Short neck.
Positive tonic reflex.
Able to hold head up with pull-to-sit
test.
Eyes
Inspect eyes, position, edema,
exudates, color of sclera, parallel
alignment, pupil size, and equality.
Test corneal/blink reflex.
Test red light reflex.
Eyes may be edematous after vaginal
delivery.
Eyes equal and symmetrical.
Blue-gray or brown iris; white or
bluish-white sclera.
Antimongolian slant; Mongolian slant
seen in Asian infants.
Positive red light reflex.
Positive blink reflex.
Positive corneal reflex.
No tears (tear production begins by 2
months).
Positive fixation on close objects.
Positive pupillary reaction to light.
Strabismus and searching nystagmus
caused by immature muscular control.
** Avoid bright light because it will cause
the newborn to avoid opening her or
his eyes and make assessment
difficult.
Ears
Inspect shape, position, and drainage.
Test hearing.
ALERT
The ears and kidneys develop at the same
time in utero, so malformed ears may be
accompanied by renal problems.
ALERT:
ALERT:
A newborn clitoris larger than 0.5 cm
is abnormal.
Asymmetrical posture.
Hypertonia: Tightly flexed arms and
stiffly extended legs with quivering.
Opisthotonic posture: Arched back.
Dimpling of spine, tuft of hair: May
indicate spina bifida or pilonidal cyst.
TESTING REFLEXES
Infant reflexes are often present at birth and occur because the neurological system
is immature. Many of these reflexes disappear as the neurological system develops.
Reflexes which are critical for infants survival:
1. Rooting Reflex
2. Sucking Reflex
3. Swallowing Reflex
Protective reflexes that lasts throughout life:
1. Blink or corneal Reflex
2. Papillary Reaction Reflex
3. Sneezing Reflex
4. Gag Reflex
5. Cough Reflex
6. Yawn Reflex
NEWBORN/INFANT REFLEXES
REFLEX / TECHNIQUE / NORMAL
ABNORMAL RESPONSE
RESPONSE
1. MORO
Present at birth and lasts 1 to 4
Premature or ill infants may have
months
sluggish response.
Technique: Startle infant by suddenly Positive response beyond 6 months
jarring bassinet or with infant in
indicates neurological problem.
Asymmetrical response may be
semisitting position, let head drop
caused by injury to clavicle, humerus,
back slightly.
Quickly abducts and extend arms and
or brachial plexus during delivery.
legs symmetrically.
Makes C with index finger and
thumb. Legs flex up against trunk.
2. STARTLE
Present at birth and lasts 4 months
Same as Moro.
Technique: Startle infant by making
loud noise.
Hands clenched, arms abducted,
flexion at elbow.
3. TONIC NECK
Present between birth and 6 weeks;
Response after 6 months may indicate
disappears at 4 to 6 months.
cerebral palsy.
Technique: With infant supine, rotate
head to one side so that chin is over
shoulder.
Infant assumes fencing position,
with arm and leg extended in
direction to which head was turned.
4. PALMAR GRASP
Present at birth; disappears at 3 to 4
Negative grasp seen with hypotonia or
months.
prenatal asphyxia.
Technique: Place object or finger in
palm of infants hand.
weeks.
Technique: Place infant on abdomen.
Newborn attempts to crawl.
14. CROSSED EXTENSION
Present at birth; disappears at 2
months.
Technique: Infant supine with leg
extended. Stimulate foot.
Flexion, adduction then extension of
opposite leg.
15. PULL-TO-SIT
Present at birth.
Technique: Pull infant to sitting
position.
Head lags as infant is pulled to sitting
position, but then infant is able to
hold up head temporarily.
16. TRUNK INCURVATION
Present at birth; disappears in a few
days to 4 weeks.
Technique: With infant prone, run
finger down either side of spine.
Flexion of trunk with hip moving
toward stimulated side.
17. MAGNET
Present at birth.
Technique: With infant supine, flex leg
and apply pressure to soles of feet.
Extends legs against pressure.