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Physical Assessment
of the Newborn
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Table of Contents
Normal Newborn: General Appearance Vital Signs and General Measurements Skin
Head, Eyes, Ears Nose, Mouth, Throat, and Neck Chest and Abdomen Female Genitalia and Male Genitalia
Back and Rectum. Extremities Neuromuscular System
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Normal Newborn: General
Appearance
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Vital signs : Weight
Weight : 2.5 kg 3.5 kg
Sigs of potential distress or deviation fromexpected findings
4.7 kg is unusual.. A maternal illness should be
suspected like diabetes.
75 90 %of the newborns weight is fluid.
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Vital Signs: Heart rate
Range: 120 to 160 beats per minute
Common variations: Heart rate range to 100 when sleeping to 180 when crying
Color pink with acrocyanosis
Heart rate may be irregular with crying
Signs of potential distress or deviations fromexpected findings:
Although murmurs may be due to transitional circulation-allmurmurs should be followed-up and referred for medical evaluation
Deviation from range
Faint sound
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Vital Signs: Respiration
Range: 30 to 60 breaths per minute
Common variations:
Bilateral bronchial breath soundsMoist breath sounds may be present
shortly after birth
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Vital Signs: BP
Blood pressure - not done routinelyFactors to consider: Varies with change in activity level
Appropriate cuff size important for accurate reading Average newborn (1 to 3 days) oscillometry pressure value:
65/41 in both upper and lower extremities
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Vital Signs: Temperature
Range: 36.5 to 37.5 rectal
36.5 37.2 axillary
Common variations:
Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery
Signs of potential distress or deviations
from expected findings: Temperature is not reliable indicator of infection
A temperature less than 36.5
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Vital Signs
Newborn lose heat by 4 mechanism:a.Convection
b.Conductionc. Radiationd.Evaporation
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Important terms to
remember:
Brown fats
Kangaroo care.
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Normal newborn
General appearance
Well flexed full range of motion , spontaneous
movement.
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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 color Edema around eyes, feet, and genitals Vernix caseosa - white, cheesy substance covering the newborn's
body. Often present only in the skin folds. Lanugo - Fine downy body hair usually distributed over shoulders,
sacral area, and back of newborns. Usually disappears before birthor shortly after birth.
Turgor good with quick recoil Hair silky and soft with individual strands
Nipples present and in expected locations Cord with one vein and two arteries Cord clamp tight and cord drying
Nails to end of fingers and often extend slightly beyond
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Skin: Expected findings
Skin reddish in color, smooth and puffy at birth
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Skin: Common Variations
Acrocyanosis - result of sluggish peripheral circulation
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Skin: Common Variations
Mongolian spots in infants
of African-American descent
Patch of purple-black or
blue-black colordistributed overcoccygeal and sacralregions of infants ofAfrican-American or
Asian descent.
Not malignant.
Resolves in time.
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Skin: Common Variations
Mottling: Generalized red and white discoloration of skin of chilled
infants with fair complexion.
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Skin: Common Variations
Physiologic Jaundice:
Hyperbilirubinemia not associated with hemolytic disease or otherpathology in the newborn
Jaundice that appears in full term newborns 24 hours after birth andpeaks at 72 hours
Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.
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Skin: Common Variations
Milia: Tiny white papules (plugged sebaceous glands) located
over nose, cheek, and chin.
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Skin: Common Variations
Erythema toxicum:
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Skin: Common Variations
Petechiae/ bruises over presenting part
Petechiae:
Pinpoint, flat hemorrhages often visualized onhead, face, and chest. Associated with rapidonset of pressure followed by immediaterelease of pressure during birthing process.
Bruises/Ecchymoses: Larger than petechia, hemorrhagic areas
associated with rapid delivery or breech birth.
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Skin: Common Variations
Skin tags usually around ears or digits(tied off)
Harlequin color change:
The color of the newborn's body appears tobe half red and half pale. This condition istransitory and usually occurs with lusty crying.
Harlequin Coloring may be associated with toan immature vasomotor reflex system.
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Skin: Common Variations
Signs of potential distress or deviations from normalFindings:
Jaundice within 24 hours of birth Unconjugated bilirubin circulating in the blood stream that is deposited
in the skin
Skin color may range from yellow to orange to greenish hues. General cyanosis Circumoral cyanosis between feedings
Petechiae or ecchymoses other than on presenting part All rashes with exception of erythema toxicum Pigmented nevi
Yellow vernix Hemangioma
Pallor
Forceps marks
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Skin: Common Variations
Forceps marks:
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Desquamation : within 24 hours of birth,the skin of the newborn has become dry ,
particularly evident in the palm o the handand sole of the feet.
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Vernex caseosa : a white cream likesubstance that serves as skin lubricant.
The color of the vernix carefully noted because ittakes on the color of the amniotic fluid.
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Lanugo. : is a fine downy hair thatcover the newborn shoulder, back andupper arm
Age of two weeks they are disappear.
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Birth marks
Hemangiomas
Nevus flammeus :
Dark lesions commonly called port wine stain due to itsdeep color.
Do not fade either.
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Straberry hemangiomas :Elevate areas that forms by immature capillaries and
endothelial cells.
Appear in termed neonates appear up to 2 weeks.
Not present in preterm infants. Becauseof immature epidermis.
Up to 10 ears older before its complete absorption.
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Cavernous heangiomas : are dilatedvascular spaces. They are usually raised andresemble a strawberry hemangiomas in appearance.
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Craniotabes : is localized softening of thecranial bones. The bones is so soft that theexamminindg finger can indent it..
The condition correct itself without treatment.
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Normal NewbornGeneral Appearance:
A. Head
symmetry
-minor asymmetry is common and should
equalize by approximately 4 mos.
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General Measurements
Head circumference: 33 to 35 cm
Expected findings Head should be 2 to 3 cm larger than
the chest
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HEAD: Expected findings
Anterior fontanel - diamond shaped 2-3 -3-4 cm
Posterior fontanel - triangular 0.5 - 1 cm
Fontanels should be soft, firm and flat
Sutures should palpable with small
separation between each Forehead is large and prominent
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Head: Common Variations
Caput succedaneum: Swelling of the soft tissue of
the scalp caused bypressure of the fetal head on
a cervix that is not fullydilated.
Swelling crosses suture lineand decreases rapidly in afew days after birth.
Reabsorb within 12 hoursafter birth or few days
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Head: Common Variations
Molding of fontanels and suture spaces
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Head: Common Variations
Signs of potential
distress or deviations
from normal findings:
Fontanels that arebulging or depressed
Hydrocephalus
Macrocephaly
Cephalhematoma
Closed sutures
Cephalhematoma
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Head: Common Variations
Cephalhematoma:
Subperiosteal extravasation of blood due ruptureof vessels.
Swelling increases in size on second and thirdday after delivery.
Often associated with delivery by forceps.
Swelling does not cross suture line and may
take several weeks after birth. Jaundice may occur as blood cells are broken
down as the swelling resolves.
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Neck: Expected Findings
Short and thick
Turns easily side to side
Clavicles intact Tonic neck reflex present
Neck-righting reflex present
Some head control
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Neck
Signs of potential distress or deviations
from expected findings:
Torticollis-stiff neck drawing head to one
side Resistance to flexion
Webbing of neck
Large fat pad on back of neck
Palpable crepitus, movement with palpationof clavicle
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Turner syndrome: Abnormal skin foldsover the back of the neck can be a marker of for
genetic abnormality
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Examining the neck
In newborn and infant. Nuchal rigidity is a morereliable indicator of meningeal irritation than is brudzinskisign or kernigs sign
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Normal newborn
-bruised &/or puffy eyelids are normal
-sclerae white to bluish white; slightly brownish frequent innewborns of African descent
-small conjunctival, scleral & retinal
-erythromycin & tetracycline are now frequently usedprophylactically instead of silver nitrate. If silver nitrate drops areused, it may cause edema & chemical conjunctivitis which mayappear a few hrsafter instillation and disappear in 1-2 days
Eyes
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Eyes: Expected findings
Slate gray or blue eye color
No tears
Fixation at times - with ability to follow objects to midline
Red reflex
Blink reflex
Distinct eyebrows
Cornea bright and shiny
Pupils equal and reactive to light
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Red reflex : Is extremely important inthe detection of retinoblastoma, a childhood
eye cancer.
Red reflex absent
Red Reflex Absent
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Eyes: Common Variations
Edematous eyelids: Uncoordinated movements:
May focus for a few seconds
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Eyes
Signs of potential distress or deviationsfrom expected findings: Discharges Opaque lenses
Absence of Red Reflex Epicanthal folds in newborns not of Oriental descent "Doll's eyes" Reflex beyond 10 days of age
When the head is moved slowly to the right or left, the eyes donot follow nor adjust immediately to the position of the head.
This reflex should not be elicited once fixation is present. The persistence of the Doll's Eyes Reflex suggests neurologic
damage.
Reflexes absent
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Eyes
Chemical conjunctivitis Subconjunctivalhemorrhage
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Ears: Expected findings
Pinna top onhorizontal linewith outercanthus of eye
Loud noiseelicits StartleReflex
Flexible pinnawith cartilagepresent
Trisomy 18 and13 syndrome.
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Ears: Common variations
Skin tags on oraround ears
Ringing a bell by 6
inches from each ear.
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Ears
Signs of potentialdistress
or deviations from
expected findings: Ear placement low
Clefts present
Malformations Cartilage absent
Preauricular sinus
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Nose: Expected findings
Nostrils patent bilaterally
Obligate nose breathers
No nasal discharge
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Nose: Common variations
Sneezes to clear nostrils
Bridge appears absent
Thin white nasal mucus discharge
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Nose
Signs of potential distress or deviations
from expected findings
Choanal atresia and discharge
Malformation
Nasal flaring beyond first few moments
after birth
M th & Th t
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Mouth & Throat:
Expected Findings Mucosa moist. Shortly after birth may visualize
sucking calluses on central portions of lips.
Mouth & Throat
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Mouth & Throat:
Expected Findings Palate high arched Uvula midline Minimal or absent
salivation
Tongue moves freely anddoes not protrude Well developed fat pads
bilateral cheeks Sucking reflex
Rooting reflex Gag reflex Extrusion reflex
Mouth & Throat:
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Mouth & Throat:
Common Variations
Epstein's pearls on ridges of gums
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Thrush : Candida infection : usuallyappear on the tongue and side of the
chicks are as white or as gray patches.
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Mouth & Throat
Signs of potential distress or deviations
from expected findings:
Cleft lip or cleft palate
Circumoral pallor Lip movement asymmetrical
Reflexes absent or incomplete
Protruding tongue
Candida Albicans
Diminished tongue movement
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Mouth & Throat
Candida Albicans Percocious teeth
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Physiologic function
Cardiovascular system
Blood Values : newborn blood volume is 80 110 ml per kilogram (300 ml )
Newborn common have high erythrocyte count 6 million percubic mm. and increase hemoglobin average of 17 18g/100ml and hemactocrit 4 and 50%
Newborn usually high in WBC at birth 15000 30000 cells
/mm3 . As high as 40000 if birth is stressful
Blood coagulation:most newborn have prolong coagualtion time
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Chest: Expected Findings
Evident xiphoid process
Equal anteroposterior and lateral diameter
Bilateral synchronous chest movement
Symmetrical nipples
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Chest: Common Variations
Witch's milk
Enlarged breasts
Accessory nipples
Fluid should neverexpressed frominfants breast.
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Urinary System
Average newborn void within 24 hours after birth. (24hours is the golden rule.
Male should void with enough force to produce projected
arc.
Female : produce a steady stream , not a continuousdribbling.
Usually light colored and odorless.Specific gravity : 1.008 1.0101st voiding: :pink or dusky because of uric crystal thatformed in the bladder in utero
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Gastrointestinal system
StoolStool passed within 24 hours after birth. Consist of meconium ( blackish green, odorlessmaterial
If not pass within 24 48 hours check for possibility of of
imperfobnate anus
2nd and third day stools ( transitional stool.)
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Newborn with bile obstruction:will have clay colored gray stools.
Because of bile pigments do not enterthe intestinal tract
Newborn under photo therapy
Bright green stools because of increase bilirubinexcretion.
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Immune system:
Passive anti bodies ( IgG ) againstpoliomellitis, measles diptheria,
pertusis ,chicken pox rubella andtetanus.
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Pallor : pallor is the result of anemia:
1. Excessive blood loss when the cord is cut.
2. addewquate floww of blood from the cord in to the infant at birth.
3. Fetal maternal transtransfusion
4. Low iron stores that caused by poor maternal nutrition during pregnancy
5. Blood incompatibility which large number of RBC were hemolzed in
utero.
7. Internal bleeding.
GRAY colored newborn generally indicates infection
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At about 20 mg / 100 mlKernicterus.
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Harlequin sign
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Twins transfusion phenomenon:
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Abdomen: Expected Findings
Dome-shaped abdomen Abdominal respirations Soft to palpation Well formed umbilical cord
Three vessels in cord Cord dry at base Liver papable 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
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Abdomen: Common Variations
Small umbilical hernia
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Abdomen
Signs of potential distress or deviationsfrom expected findings:
Bowel sounds absent
Peristaltic waves visible
Abdominal distention Palpable masses
Scaphoid-shaped abdomen
Omphalocele
Base of cord with redness or drainage Cord with two vessels
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Female Genitalia
Expected findings:
Edematous labia and clitoris
Labia majora are larger and surroundinglabia minora
Vernix between labia
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Female Genitalia
Common variations:
Hymenal tag
Pseudomenstruation
Smegma Increased pigmentation
Ecchymosis and edema after breech birth
"Red brick" pink-stained urine due to uric acidcrystals
G
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Female Genitalia
Signs of potential distress or deviationsfrom expected findings:
Labia fused
Fecal discharge from vaginal opening Imperforate hymen
Ambiguous genitalia
Widely separated labia
M l G i li
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Male Genitalia
Expected findings:
Urinary meatus at tip of glans penis
Palpable testes in scrotum
Large, edematous, pendulous scrotum,with rugae
Smegma beneath prepuce
Stream adequate on voiding
M l G i li
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Male Genitalia
Common variations:
Prepuce ( foreskin ) covering urinarymeatus
Erections
Increased pigmentation
Edema and ecchymosis after breechdelivery
M l G i li
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Male Genitalia
Signs of potential distress or deviationsfrom expected findings:
Non palpable testes
Hypospadius ( ventral surface ) Epispadius ( dorsal surface )
Scrotum smooth
Ambiguous genitalia
B k d R t
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Back and Rectum
Expected findings:
Intact spine without masses or openings
Trunk incurvature reflex
Patent anal opening
"Wink reflex" present
B k d R t
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Back and Rectum
Signs of potential distress or deviationsFrom expected findings: Limitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cyst
E t iti
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Extremities
Expected findings: 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
E t iti
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Extremities
Palmar creasespresent
Sole creases present
Negative hip click Grasp reflex present
E t iti
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Extremities
Signs of potential
Distress or
deviations from
expected findings: Unequal tone
Asymmetrical movement
of extremities Polydactyly
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Syndactyly
E t iti
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Extremities
Syndactyly
Unequal leg length
Asymmetrical skin
creases posteriorthigh
Simean crease
Persistent cyanosis ofnail beds
E t iti
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Extremities
Dislocation of hip
Marked metatarusvarus
N l S t
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Neuromuscular System
Expected findings:
Maintains position of flexion
When prone, turns head side to side
Holds head and back in horizontal planewhen held prone
Ability to hold head momentarily erect
Neuromuscular System
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Neuromuscular System
Signs of potential distress or deviations
from expected findings:
Hypotonia
Quivering Limp extremities or straightening of extremities
Clonic jerking
Paralysis
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