ASSESSING THE NEWBORN AND INFANTEach 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 (1–11 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.

PERFORMING A GENERAL SURVEYBefore you perform your head-to-toe assessment of the newborn, ask yourself the following questions and record your observations as baseline data.

Integumentary: Are there any abrasions, lacerations,or birthmarks?If so,describe them, and monitor for infection, bleeding, and trauma.Head and Neck: Are there masses on the head or neck? These may indicate cephalohematoma or a fractured clavicle.Eyes, Ears, Nose, Mouth, and Throat:Are there exudates in the eyes? If so, monitor for infection. Is the baby blinking? Do his or her eyes follow an object within 8 inches?Is there discharge from the ears, nose, and throat or nose congestion?Fluid may be from delivery or could indicate infection. Does the newborn respond to sound?A reaction to sound should occur.Respiratory Characteristics, Lungs, and Breathing:Is the newborn congested or gasping for breath? Fetal fluid that remains in the lungs can cause airway obstruction.Cardiovascular Characteristics: Is there cyanosis? It may denote poor vascular profusion. Is the newborn alert? A newborn in difficulty will demonstrate irritability or be unarousable.Temperature Regulation: Is body temperature maintained?Newborns are poor regulators of body temperature and are dependent on their environment for warmth. Cold stress can cause respiratory distress.Hepatic Regulation: Does the newborn have jaundice?Increasing jaundice denotes increased blood bilirubin, which can cause mental deterioration if untreated.Gastrointestinal Adaptation: Has the newborn passed stool? This proves that an anus is present.Has she or he vomited? Persistent vomiting suggests intestinal obstruction.Genitourinary Adaptation: Has the baby voided?Voiding denotes kidney function.Neurological Characteristics: How are extremities moving? Muscle tone should be symmetrical and not flaccid, extremities should be partially flexed; hand mouth behavior should be evident; and when awake, newborn should demonstrate random, purposeless, bilateral movements. How does cry sound?It should be loud, not high pitched or weak.Endocrine Characteristics: Is there evidence of fetal or maternal endocrine disease? Is the newborn jittery?Maternal diabetes can cause severe hypoglycemia in the newborn. Low glucose levels often manifest as jittery extremities.Immunologic Adaptation: Are defenses maintained?Because the newborn’s immune response is not well established, protect portals of entry (umbilical stump and breaks in skin) from infection.Sleep and Rest Patterns: What is the sleep pattern?

Newborns sleep up to 18 hours a day. The long sleep period promotes growth and development. They should awaken for feedings every 3 to 4 hours.Relationships, Psychosocial Profile, and Cultural/Ethnic Variations: How are family members relating to the newborn?The newborn is dependent on the family for its well-being. Parents should demonstrate touching and holding of infant. Assist in the bonding process. Responses may vary depending on cultural/ethnic variations.

PERFORMING A NEWBORN HEAD-TO-TOE PHYSICAL ASSESSMENTAREA / SYSTEM / NORMAL FINDINGS ABNORMAL FINDINGS / RATIONALE

1. POSTURE Inspect posture. Head and extremities flexed.

Limp posture with extension of extremities: Associated with birth injuries, anesthesia, acidosis, hypoglycemia, hypothermia, or congenital problems.

2. HEAD CIRCUMFERENCE Measure head circumference. 33 to 35 cm.Measure head circumference from occiput to

forehead.

Head circumference < 10% of normal: Microcephaly related to congenital malformation or infection.

Head circumference > 90% of normal: Macrocephaly related to hydrocephalus.

3. CHEST CIRCUMFERENCE Measure chest circumference.Measure chest at nipple line.

30.5 to 33 cm (2 to 3 cm less than head). Breast engorgement can affect measurement.

4. ABDOMINAL CIRCUMFERENCE Measure abdominal circumference.Measure abdomen above the umbilicus.

Similar to chest measurement. Should not be distended.

5. LENGTH Measure length. Crown to rump: 31 to 35 cm (about equal to

head circumference). Head to heel: 45 to 55 cm (18 to 22 inches) at

birth. Molding can affect measurement.

6. WEIGHT Weigh newborn.

Newborn weight is usually between 2500 and 4000 g (5 lb, 8 oz, and 8 lb, 13 oz).

Birth weights < 10 or > 90 percent are abnormal.

Low birth weight (small for gestational age): Associated with prematurity.

Macrosomic infant (large for gestational age): Associated with gestational diabetes in mother.

7. TEMPERATURE Take newborn’s temperature. Axillary: 36.5 to 37.20C

Hypothermia leads to cold stress. Sepsis, environmental extremes, and neurological problems can cause hypothermia or hyperthermia.

8. PULSE Auscultate heart rate. Apical rate 120 to 160 BPM.Rate increases with crying and decreases with sleep.

Irregular rhythms such as bradycardia (<100 BPM) and tachycardia (>160 BPM).

Most murmurs are not pathological and disappear by age 6 months.

9. RESPIRATIONS Take newborn’s respirations. 30 to 60 breaths a minute; irregular.Anesthesia during labor and delivery can affect

respirations.

Respirations < 30 or > 60 breaths a minute. Periods of apnea > 15 seconds.

10. BLOOD PRESSURE Take newborn’s BP. Low BP: May be caused by hypovolemia.

Systolic: 50 to 75 mm Hg. Diastolic: 30 to 45 mm Hg.Crying and moving increase systolic pressure.

Late clamping of umbilical cord can increase BP because of expanded blood volume from the “placental transfusion.”

11. INTEGUMENTARYSkin 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

baby’s 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 neonate’s nails.

Persistent acrocyanosis: May indicate thermoregulation problem or hypoglycemia.

Extensive desquamation: Seen in post-term baby

Pathological jaundice occurs within first 24 hours.

Plethora: May indicate polycythemia. Pallor: May indicate anemia, hypothermia,

shock, or sepsis. Persistent ecchymosis or petechiae: May be

caused by thrombocytopenia, sepsis, or congenital infection.

Poor turgor: Intrauterine growth retardation or hypoglycemia.

Café-au-lait spots (light brown spots): If more than six or larger than 4 x 6 cm, may indicate neurofibromatosis and can become precancerous with age.

Nevus flammeus (port-wine stain): Disfigures face and may be associated with cerebral vascular malformation.

Giant hemangiomas and nevus vasculosus (“strawberry marks”) tend to trap platelets and lower circulating platelet counts. They usually disappear by age 5.

Reddish-blue round mass of blood vessels (cavernous hemangioma) must be monitored, and if size increases, surgery may be necessary.

Erythema toxicum, a common newborn rash of red macules and papules, usually disappears in 1 week.

Bullae or pustules: May indicate infections such as syphilis or staphylococcus.

Thin, translucent skin and vernix caseosa are signs of prematurity.

Genetic disorders may cause extra skin folds. Abundant lanugo is a sign of prematurity. Genetic disorders may cause abnormal hair

distribution unrelated to gestational age. Long nails are seen in post-term babies.

12. HEENTHead/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.

Fused sutures. Large fontanels: Associated with hydrocephaly,

osteogenesis imperfecta, congenital hypothyroidism.

Small fontanels: Associated with microcephaly. Bulging fontanels: May indicate increased

intracranial pressure. Depressed fontanels: Associated with

dehydration. Craniosynostosis (premature closure of the

sutures). Cephalohematoma (hematoma between

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. Pinna flexible, without deformity, aligns with

external canthus of eyes. Positive startle reflex.

Nose Inspect nares. Nares patent. Small amount of thin white mucus. Nose may be flattened and bruised from birth.

Mouth/Throat Inspect mucous membranes, lips, tongue, and

palate. Test sucking, rooting, gag, extrusion and

periosteum and skull with unilateral swelling). Most uncomplicated cephalohematomas totally

resolve within 2 weeks to 3 months. Caput succedaneum (edema of soft scalp tissue

from birth trauma) decreases gradually in several days.

Asymmetrical facial movements: May result from damage to facial nerve during forceps delivery.

Absent tonic reflex: Erb’s palsy if unilateral or dislocation of cervical spine or fractured clavicle.

Head lag with “pull-to-sit” test: Muscle weakness.

Torticollis (wry neck).

Subconjunctival hemorrhage: Trauma during delivery.

Brushfield spots (speckling of iris), epicanthal fold, and Mongolian slant: Down syndrome.

Absent red light reflex: May indicate congenital cataract.

Ptosis: Neuromuscular weakness. Sun-setting (crescent of sclera over iris caused

by retraction of upper lid): Hydrocephalus. Yellow sclera: Jaundice. Blue sclera: Osteogenesis imperfecta. Persistent nystagmus, absent blink reflex,

inability to follow objects: May indicate vision problem, such as blindness.

Dilated or fixed pupil: May indicate anoxia or neurological damage.

Chemical conjunctivitis from eye prophylaxis may occur during first 24 hours.

Low-set ears: Down syndrome. Absent startle reflex: Possible hearing problem.

Because infants are obligatory nose breathers, large amounts of mucus drainage may obstruct nostrils and cause respiratory difficulty.

Nasal flaring: Sign of distress.

Cyanotic mucous membranes: Hypoxia. Candida albicans (thrush): Contracted during

vaginal delivery.

swallowing reflexes. Mucous membranes pink and moist. Frenulum of tongue and lip intact. Palate intact, uvula midline. Strong sucking reflex, positive rooting, gag,

extrusion, and swallowing reflexes. Minimal saliva. Strong cry. Natal teeth may be benign or associated with

congenital defects.** Natal teeth must be removed by a specialist because

they usually fall out and can cause choking.

Small white, pearl-like epithelial cysts on the palate (Epstein’s pearls), disappear within a few weeks.

Weak sucking, swallowing reflex: May be caused by maternal anesthesia or perinatal asphyxia.

Opening in palate or lips: Cleft palate or lip. Any opening is abnormal. A series of surgical interventions will be necessary.

Weak cry: May indicate neuromuscular problem, hypotonia, and prematurity.

A L E R T The ears and kidneys develop at the same time in

utero, so malformed ears may be accompanied by renal problems.

Cleft lip or palate will cause newborn to have difficulty with feeding

13. CHEST Inspect shape, symmetry, and chest excursion. Inspect breast size, drainage. Anteroposterior:lateral (1:1). Equal chest excursion. Breast engorgement. Clear or milky liquid from nipples (“witch’s

milk”) develops from maternal hormones in utero.

Supernumerary nipples are a benign finding.

Funnel chest (pectus excavatum): Congenital anomaly.

Pigeon chest (pectus carinatum): Obstructed respiration in infancy.

Asymmetrical excursion, retraction: Respiratory distress.

Red, firm nipples.

14. RESPIRATORY Auscultate breath sounds. Lungs clear, bronchial to bronchovesicular

breath sounds audible. Cough reflex absent at birth, but present 1 to 2

days later. Scattered crackles a few hours after birth.

Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, prolonged periods of apnea (>15 to 20 sec) are signs of respiratory problems.

15. CARDIAC Auscultate heart sounds. S1, S2, normal rhythm with respiratory

variations. PMI fourth left intercostal space midcostal line.

** Quiet but clearly audible murmurs occur in 30 percent of newborns but should disappear in 2 days.

Dextrocardia (heart on right side). Cardiomegaly: Displaced point of maximal

impulse (PMI). Murmurs are often heard at base or along left

sternal border, and are usually benign, but need to be evaluated to rule out cardiac disorder.

Thrills.

16. ABDOMEN Inspect abdomen and umbilical cord. Note hernias or diastasis recti. Gently palpate abdomen and femoral pulse. Auscultate bowel sounds. Abdomen round. Positive bowel sounds. Liver edge palpable 2 to –3 cm. Tip of spleen, kidneys palpable. Cord bluish white with two arteries and one

vein. Positive femoral pulses. Umbilical hernias and diastasis recti (separation

of rectus muscles) more common in African American infants and often resolve within a year.

Abdominal distension, ascites, distended veins: May indicate portal hypertension.

Green umbilical cord: May indicate infection. Absence of umbilical vessels: Associated with

heart and kidney malformations.

17. RECTUM Inspect anus. Anus patent. Passage of meconium stool within 48 hours. Positive anal reflex (“anal wink”).

Anal fissures or fistulas. No stools: May indicate malformation in

gastrointestinal (GI) tract.

ALERT: Imperforate anus (absent anus) requires

immediate surgical repair.18. FEMALE GENITALIA Inspect genitalia. Place thumbs on either side of

labia and gently separate tissues to visualize perineum.

Note presence of clitoris, vagina, and hymen. Urination within 24 hours. Urinary meatus is midline and an uninterrupted

stream is noted on voiding. Labia majora and minora may be edematous. Blood-tinged vaginal fluid may be noted

(pseudomenstruation).

Fused labia or absent vaginal opening. Ambiguous genitalia. Meconium from vaginal opening. Inability to urinate within 24 hours.

ALERT: A newborn clitoris larger than 0.5 cm is

abnormal.

19. MALE GENITALIA Inspect penis and note position of urinary

meatus. Retract foreskin. Palpate scrotum, and note undescended

testicle if present. Urination within 24 hours. Foreskin retracts. Urethral opening at tip of penis. Scrotum edematous. Smegma. Palpable testes.

Hypospadias (urethral opening on ventral surface of penis).

Epispadias (urethral opening on dorsal side of penis).

Chordee (ventrally curved penis). Hydrocele (fluid in scrotum). Inability to urinate within 24 hours. Inability to retract foreskin. Undescended testicles. Inguinal hernia. Ambiguous genitalia. Meconium from scrotum.

20. MUSCULOSKELETAL Inspect extremities, and note number of digits

and deformities. Inspect spine, and note shape. Inspect gluteal folds. Perform Barlow-Ortolani maneuvers. 10 fingers and 10 toes. Full ROM. No clicks in joints. Equal gluteal folds. C curve of spine, no dimpling. When arms and legs are extended: Muscles symmetrical and with equal muscle

tone. Arms and legs symmetrical in size and

movement. Hands held as fists until after 1 month, when

grasp becomes strong and equal. Position in utero may affect appearance.

Polydactyly: Extra digits. Syndactyly: Webbed digits. Phocomelia: Hands and feet attached close to

chest. Hemimelia: Absence of distal part of extremity. Talipes (clubfoot): Foot permanently twisted

out of shape. Severe bowing of legs is abnormal. Unequal gluteal folds and positive Barlow-

Ortolani maneuver: Associated with congenital hip dislocation. Requires immediate referral.

Decreased ROM and muscle tone. Swelling, crepitus, neck tenderness: Possible

broken clavicle. Simian (transverse palmar) creases: Down

syndrome.

21. NEUROLOGICAL Test the newborn’s reflexes. Positive newborn reflexes. Positive knee reflex.

Hypotonia: Floppy, limp extremities. Paralysis. Marked head lag. Tremors. 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 REFLEXESInfant 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 infant’s survival:

1. Rooting Reflex2. Sucking Reflex3. Swallowing Reflex

Protective reflexes that lasts throughout life:1. Blink or corneal Reflex2. Papillary Reaction Reflex3. Sneezing Reflex4. Gag Reflex5. Cough Reflex6. Yawn Reflex

NEWBORN/INFANT REFLEXESREFLEX / TECHNIQUE / NORMAL RESPONSE ABNORMAL RESPONSE

1. MORO Present at birth and lasts 1 to 4 months Technique: Startle infant by suddenly jarring

bassinet or with infant in semisitting position, let head drop back slightly.

Quickly abducts and extend arms and legs symmetrically.

Makes “C” with index finger and thumb. Legs flex up against trunk.

Premature or ill infants may have sluggish response.

Positive response beyond 6 months indicates neurological problem.

Asymmetrical response may be caused by injury to clavicle, humerus, or brachial plexus during delivery.

2. STARTLE Present at birth and lasts 4 months Technique: Startle infant by making loud noise. Hands clenched, arms abducted, flexion at

elbow.

Same as Moro.

3. TONIC NECK Present between birth and 6 weeks; disappears

at 4 to 6 months. 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.

Response after 6 months may indicate cerebral palsy.

4. PALMAR GRASP Present at birth; disappears at 3 to 4 months. Technique: Place object or finger in palm of

infant’s hand. Infant grasps object tightly. If he or she grasps

your fingers with both hands, infant can be pulled to a sitting position.

Negative grasp seen with hypotonia or prenatal asphyxia.

5. PLANTAR GRASP Present at birth; disappears at 3 to 4 months. Technique: Place thumb firmly against ball of

infant’s foot. Toes flex tightly downward in a grasping

motion.

Negative grasp seen with hypotonia or spinal cord injury.

6. BABINSKI Present at birth; disappears at 1 year. Technique: Stroke lateral surface of sole of

infant’s foot. Toes should fan.

Diminished response associated with neurological problem.

7. STEPPING OR DANCING Present at birth; disappears at 3 to 4 weeks. Technique: Hold infant upright with her or his

feet touching a flat surface. Infant steps up and down in place.

Poor response caused by hypotonia.

8. ROOTING Present at birth; disappears at 3 to 6 months. Technique: Brush cheek near corner of mouth. Infant turns head in direction of stimulus and

opens mouth.

Prematurity or neurological problem may cause weak or absent response.

9. SUCKING Present at birth; disappears at 10 to 12 months. Technique: Touch lips. Sucking motion occurs.Don’t check for rooting or sucking responses

immediately after a feeding—they will be difficult to elicit.

Weak or absent response associated with prematurity or neurological defect.

10. SWALLOWING Present at birth and lasts throughout life. Technique: Automatically follows sucking

response during feeding. Sucking and swallowing should occur without

coughing, gagging, or vomiting.

Weak or absent response associated with prematurity or neurological problem.

11. EXTRUSION Present at birth and lasts 3 to 4 months. Technique: Touch tip of tongue. Tongue protrudes outward.

Absence may indicate neurological problem. Continued extrusion of large tongue associated

with Down syndrome.12. GLABELLAR Present at birth. Technique: Tap on forehead. Newborn blinks for first few taps.

Persistent blinking with repeated taps indicates extrapyramidal problem.

13. CRAWLING Present at birth; disappears at 6 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.

Peripheral nerve damage causes weak response.

Spinal cord lesion causes absent response.

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.

Inability to hold up head suggests prematurity or hypotonia.

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

Absent response indicates neurological or spinal cord problem.

stimulated side.17. MAGNET Present at birth. Technique: With infant supine, flex leg and

apply pressure to soles of feet. Extends legs against pressure.

Breech birth may diminish reflex. Absent response caused by spinal cord

problem.