normal newborn screening
TRANSCRIPT
Normal Newborn: General Appearance
Well-flexed, full range of motion, spontaneous movement
Common variations
Legs extended with frank breech
Signs of potential distress or deviations from expected findings
Posture limpAsymmetry of movementPersistent tremor, twitching
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Vital Signs
Temperature - range 36.5 to 37 axillary
Common variations
Crying may elevate temperatureStabilizes in 8 to 10 hours after delivery
Signs of potential distress or deviations from expected findings
Temperature is not reliable indicator of infectionA temperature less than 36.5
Heart rate - range 120 to 160 beats per minute
Common variations
Heart rate range to 100 when sleeping to 180 when cryingColor pink with acrocyanosisHeart rate may be irregular with crying
Signs of potential distress or deviations from expected findings
Although murmurs may be due to transitional circulation-all murmursshould be followed-up and referred for medical evaluation
Deviation from rangeFaint sound
Respiration - range 30 to 60 breaths per minute
Common variations
Bilateral bronchial breath soundsMoist breath sounds may be present shortly after birth
Signs of potential distress or deviations from expected findings
Asymmetrical chest movementsApnea >15 secondsDiminished breath soundsSeesaw respirationsGruntingNasal flaringRetractionsDeep sighingTachypnea - respirations > 60Persistent irregular breathingExcessive mucusPersistant fine cracklesStridor
Blood pressure - not done routinely
Factors to consider
Varies with change in activity levelAppropriate cuff size important for accurate readingAverage newborn (1 to 3 days) oscillometry pressure value: 65/41 in
both upper and lower extremities
Sign of potential distress or deviations from expected findings
Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta
General Measurements
Head circumference - 33 to 35 cm
Expected findings
Head should be 2 to 3 cms larger than the chest
Chest circumference - 30.5 to 33 cm
Common variations
Molding of head may result in a lower head circumference measurement
Head and chest circumference may be equal for the first 24 to 48 hours of life
Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)
Length range - 48 to 53 cms (19 - 21 inches)
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Skin
Expected findings
Skin reddish in color, smooth and puffy at birth
At 24 - 36 hours of age, skin flaky, dry and pink in colorEdema around eyes, feet, and genitalsVernix caseosa LanugoTurgor good with quick recoilHair silky and soft with individual strandsNipples present and in expected locationsCord with one vein and two arteriesCord clamp tight and cord dryingNails to end of fingers and often extend slightly beyond
Common variations
Acrocyanosis - result of sluggish peripheral circulation
Mongolian spots in infants of African-American descent
Mottling
Physiologic jaundice
Milia
Erythema toxicum
Petechiae/ bruises over presenting partSkin tags usually around ears or digits (tied off) Harlequin color change
Signs of potential distress or deviations from normal findings
Jaundice within 24 hours of birthGeneral cyanosisCircumoral cyanosis between feedingsPetechiae or ecchymoses other than on presenting partAll rashes with exception of erythema toxicumPigmented neviYellow vernixHemangiomaPallorForceps marks
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Head
Expected findings
Anterior fontanel diamond shaped 2-3 - 3-4 cmsPosterior fontanel triangular 0.5 - 1 cmFontanels soft, firm and flatSutures palpable with small separation between each
Common variations
Caput succedaneum
Molding of fontanels and suture spaces
Signs of potential distress or deviations from normal findings
Fontanels that are bulging or depressedHydrocephalusMacrocephalyCephalhematoma
Closed sutures
Eyes
Expected findings
Slate gray or blue eye colorNo tearsFixation at times - with ability to follow objects to midlineRed reflexBlink reflexDistinct eyebrowsCornea bright and shinyPupils equal and reactive to light
Common variations
Edematous eyelids
Uncoordinated movements
May focus for a few seconds
Signs of potential distress or deviations from expected findings
DischargesChemical conjunctivitis
Opaque lensesAbsence of Red ReflexEpicanthal folds in newborns not of Oriental descent"Doll's eyes" beyond 10 days of age
Reflexes absentSubconjunctival hemorrhage
Ears
Expected findings
Pinna top on horizontal line with outer canthus of eye
Loud noise elicits Startle ReflexFlexible pinna with cartilage present
Common variations
Skin tags on or around ears
Signs of potential distress or deviations from expected findings
Ear placement lowPreauricular sinus
Clefts presentMalformationsCartilage absent
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Nose
Expected findings
Nostrils patent bilaterallyObligate nose breathersNo nasal discharge
Common variations
Sneezes to clear nostrilsBridge appears absentThin white nasal mucus discharge
Signs of potential distress or deviations from expected findings
Choanal atresia and dischargeMalformationNasal flaring beyond first few moments after birth
Mouth and Throat
Expected findings
Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.
Palate high arched
Uvula midlineMinimal or absent salivationTongue moves freely and does not protrudeWell developed fat pads bilateral cheeksSucking reflexRooting reflexGag reflexExtrusion reflex
Common variations
Epstein's pearls on ridges of gums
Signs of potential distress or deviations from expected findings
Cleft lip or cleft palateCircumoral pallorLip movement asymmetricalReflexes absent or incompleteProtruding tongueCandida Albicans
Diminished tongue movementPercocious teeth
Neck
Expected findings
Short and thickTurns easily side to sideClavicles intactTonic neck reflex presentNeck-righting reflex presentSome head control
Signs of potential distress or deviations from expected findings
Torticollis-stiff neck drawing head to one sideResistance to flexionWebbing of neckLarge fat pad on back of neckPalpable crepitus, movement with palpation of clavicle
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Chest
Expected findings
Evident xiphoid processEqual anteroposterior and lateral diameter Bilateral synchronous chest movementSymmetrical nipples
Common variations
"Witch's milk"Enlarged breastsAccessory nipples
Signs of potential distress or deviations from expected findings
Asymmetrical chest movementsSternum depressedMarked retractionsAbsent breast tissueFlattened chestSupernumerary nipplesNipples widely spaced Bowel sounds auscultated
Abdomen
Expected findings
Dome-shaped abdomenAbdominal respirationsSoft to palpationWell formed umbilical cordThree vessels in cord
Cord dry at baseLiver papable 2 - 3 cms below right costal marginBilaterally equal femoral pulsesBowel sounds auscultated within two hours of birthVoiding within 24 hours of birthMeconium within 24 - 48 hours of birth
Common variations
Small umbilical hernia
Signs of potential distress or deviations from expected findings
Bowel sounds absentPeristaltic waves visibleAbdominal distentionPalpable massesScaphoid-shaped abdomenOmphaloceleBase of cord with redness or drainageCord with two vessels
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Back and Rectum
Expected findings
Intact spine without masses or openingsTrunk incurvature reflexPatent anal opening"Wink reflex" present
Signs of potential distress or deviations from expected findings
Limitation of movementFusion of vertebraeSpina bifidaTuft of hairImperforate anusAnal fissuresPilonidal cyst
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Back and Rectum
Expected findings
Intact spine without masses or openingsTrunk incurvature reflexPatent anal opening"Wink reflex" present
Signs of potential distress or deviations from expected findings
Limitation of movementFusion of vertebraeSpina bifidaTuft of hairImperforate anusAnal fissuresPilonidal cyst
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Extremities
Expected findings
Maintains posture of flexionEqual and bilateral movement and toneFull range of motion all joints Ten fingers and ten toesLegs appear bowedFeet appear flat
Palmar creases present
Sole creases present
Negative hip clickGrasp reflex present
Signs of potential distress or deviations from expected findings
Unequal toneAsymmetrical movement of extremitiesPolydactyly
SyndactylyUnequal leg lengthAsymmetrical skin creases posterior thigh
Dislocation of hip
Simean creasePersistent cyanosis of nail bedsMarked metatarus varus
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Neuromuscular System
Expected findings
Maintains postion of flexionWhen prone, turns head side to sideHolds head and back in horizontal plane when held proneAbility to hold head momentarily erect
Signs of potential distress or deviations from expected findings
HypotoniaQuiveringLimp extremities or straightening of extremitiesClonic jerkingParalysis
To return to Table of Contents. This product is still being developed. Acknowledgement:Special thanks to Robert, Barbara, and Allison Clifford for their participation in the preparation of the video clips used in this presentation.
References:Burns, C.E., Barber, N., Brady, M.A., Dunn, A.M., (1996) Pediatric Primary Care: A Handbook for Nurse Practitioners, Philadelphia, W.B. Saunders Company.
Gorrie, Trula Myers, McKinney, Emily Stone, and Murray, Sharon Smith. (1994). Foundations of maternal newborn nursing,Philadelphia; W. B. Saunders Company.
Wong, Donna L. (l995). Whaley & Wong's nursing care of infants and children; contributing editor, David Wilson. 5th edition. St. Louis: Mosby.
Variations and minor departures in infants (1994), Mead Johnson & Company: Evansville, Indiana.
Resources:CCIT staff, Duquesne University.Created by Lenore K. Resick, MSN, RN, CS, CRNP, 612 College Hall 412/396-5228, e-mail: [email protected] 1996 Duquesne University