Wallace State Community College

NUR 202
Newborn Assessment
Client’s Initials______
Date of Birth________
Gestational Age______ Student Name___Stella Clark________________________

ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

1. GENERAL ASSESSMENTS

Age ------- Newborn ---------LGA is above 90th percentile

SGA is below 10th percentile
Weight 2500 – 4000g (5lb.8oz.-8lb.13oz.)
Weight loss of 10% ok early on
Length 45-55 cm (18-22 in.)

Apgar Score

II. HEAD MEASUREMENT ---- 32 – 38 cm (13-15 in.)

Shape ----------------- Sutures palpable with small separation b/t each.

Anterior fontanel diamond-shaped, 4-5 cm, soft, & flat.
May bulge slightly when crying, Posterior fontanel triangular, 0.5-1 cm.
Normal Variations—Overriding sutures(molding). Caput succedaneum or
cephalhematoma (pressure during birth).

Size in Relation to Body ---- approximately one fourth of infant’s length ---
Small (SGA, microcephaly, anencephaly).
Large (LGA, hydrocephalus, increased intracranial pressure).
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

Fontanels -------- Normal variations: Overriding sutures (molding).

Caput succedaneum or cephalhematoma (pressure during birth).
Assess for edema/bruising

size, shape, consistency --

Anterior – Diamond-shaped, 4-5 cm, soft, & flat. May bulge when crying.
Abnormal—Depressed (dehydration, molding), full or bulging at rest
(increased intracranial pressure). Wooly, bunchy hair (preterm).
Unusual hair growth (genetic abnormalities).

Posterior – Triangular, 0.5 – 1 cm.

III. EYES ------ Symmetric. Eyes clear.

Color -----------
Movement ------------ Transient Strabismus

Reaction to Light – Pupils equal & reactive to light; Alerts to interesting sights;
Follows objects across midline; Doll’s eye sign, red reflex present;
May have subconjunctival hemorrhage or
edema of eyelids from pressure during birth.

Tears - Scant or absent

Evidence of sight – Alerts to evidence of interesting sights.

Eyelids –
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

IV. EARS Well-formed & complete

Reaction to noise – Startle response to loud noises.

Alerts to high-pitched voices.

Position – Area where upper ear meets head even with imaginary line drawn
from outer canthus of eye

Patency --

V. NOSE – May have slight flattening from pressure during birth.

Mucus – Absent

Patency – Both nostrils open to air flow.

VI. MOUTH – Gums, tongue pink. Tongue normal in size & movement.
Lips & palate intact
Reflexes
Rooting – Positive or present

Suck/Swallow – Sucking & swallowing present

Gag – Positive or present

 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

VII. NECK

Length -- Short

Mobility – Turns easily side to side

VIII. CHEST – Cylinder shape. Xiphoid process may be prominent. Symmetric

Size --

Breast Tissue – Nipples present & located properly. May have engorgement,
White nipple discharge (maternal hormonal withdrawal).

IX. RESPIRATIONS – Assess when sleeping, if possible. Observe, palpate, or auscultate

Chest & Abdomen…Normally irregular in the newborn. Assess q 30 min. till stable for 2 hr.

Rate – 30 – 60 breaths/min w/an avg. in the 40s when infant is at rest.

Rhythm – Irregular / Apnea lasting longer than 20 sec. is abnormal

Breath Sounds – Present equally throughout. Moisture normal W/I 1st hour
or 2 after vaginal birth. Cesarean may have coarse breath sounds.

Accessory Muscles – Chest movements should be symmetric & not labored

 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

X. PULSE

Rate – HR 120-160 bpm (100 sleeping, 180 crying).

Rhythm -- regular

Peripheral Circulation – Brachial, femoral, & pedal pulses present &

equal bilaterally

X1. ARMS AND HANDS

Length – Two (2) Transverse Palm Creases

Movements – Equal & bilateral movement

Muscle Tone – Flexion “Good” muscle tone not limp or saggy

Fingers – Correct number w/nails to ends of digits or slightly beyond.

Number – Correct number (5 on each extremity)

Webbing/ Position --
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XII. ABDOMEN

Contour – Rounded & soft

Musculature --

XIII. UMBILICAL CORD

Number of vessels at birth – Three (3) Vessels in cord.

Meconium passed W/I 12-48 hours. Urine passed W/I 12-24 hours
Normal Variation – “Brick dust” staining of diaper (urate crystals).

Appearance – Clamp tight & cord drying

XIV. GENITOURINARY

Female --

Labia majora dark, cover clitoris & labia minora.

Size

Appearance – Urinary meatus & vagina present

Vaginal Discharge – Small amount of white mucous vaginal discharge
Vaginal bleeding (pseudomenstruation) is normal variation
Color – Dark

Type
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

Male

Testes in Scrotum – Testes present W/I scrotal sac. Rugae on scrotum,

prepuce not retractable.

Uretheral meatus -- Note presence at tip or end of penis. Unable to perform

circumcision if abnormal placement is present

Circumcised – procedure performed & appearance.

Voidings -- First stool is Meconium (particles from amniotic fluid such as vernix,
skin cells, & hair, along with cells shed frm the intestinal tract,
bile & other intestinal secretions.

Color -- Meconium is greenish black

Amount

Frequency
XV. RECTUM

Patency – Should be patent. Sphincter tightly closed

Stools – Meconium is greenish black with a thick, stick, tarlike consistency.

Transitional stools (after meconium) are a combination of
meconium & milk stools
Color/Consistency/Frequency
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

XVI. HIPS – No hip “clunk” & check for “developmental dysplasia.”

Symmetry – Gluteal & thigh creases & knee height equal. No hip “clunk”

Femur Heads – DDH, (developmental dysplasia) femur heads are improperly

seated in the acetabulum (hip socket) of the pelvis. May be present at birth
or develop later on. It has a Female predominance. “Hip joints appear lax rather
than completed dislocated.” Affected hip has a limited ROM &
asymmetric abduction is present when child is placed supine with the
knees & hips are flexed, (pg. 1390).

XVII. BACK

Appearance – No openings observed or felt in vertebral column.

Raises Head – When Prone

XVIII. LEGS AND FEET

Length – Equal in length

Movements – Equal & bilateral movement

Muscle Tone – “Good” muscle tone/not limp or saggy

Warmth –
Toes – Good Flexion & Muscle Tone
Number – correct amount (5 on each foot) Nails to ends of digits or slightly beyond
Webbing/ Position – Polydactyly (extra digits). Syndactyly (webbing). Fused or absent digits.
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

XIX. SKIN

Color -- Pink or Tan w/acrocyanosis

Texture – Skin turgor good with quick recoil.

Birthmarks – Mongolian Spots. Nevus simplex (“stork bites”). Nevus vasculosus

(strawberry hemangioma). Café au lait spots (6 or more or 0.5 cm in size
(neurofibromatosis).

Characteristics

Milia – Normal Variation

Lanugo – Small amounts over shoulders, sides of face, forehead, upper back.

Vernix Caseosa – small amount in creases

Ecchymosis --

Hair

Nails

Desquamation
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

XX. TEMPERATURE

Infant’s Temperature – Axillary: 36.5 – 37.3 C (97.7 – 99.1 F)

Preferred Site is AXILLARY
Rectal: 36.5 – 37.7 C. (97.7 – 99.8 F)

Temperature regulatory – Decreased temp/cold (hypoglycemia, infection, CNS problem

Mechanisms Increased temp/too warm (infection)

Heat Loss -- Hypothermia

XXI. REFLEXES
Assess the newborn for
Presence or absence of
each reflex

Strength of each reflex

Local
Blink

Pupillary

Doll’s Eye’s

Grasp

Babinski
 ASSESSMENT TEXTBOOK INFORMATION INFANT ASSESSMENT

Generalized

Moro (Startle)

Tonic Neck (Fencing)

Dance/Walking

XXII. CRY --- Should be Lusty & Strong

Frequency – Transient in relation to hunger or sensation(s)/environmental stimulus

Pitch --
Abnormal is high-pitched (increased intracranial pressure).
Weak, absent, irritable, catlike “mewing” (neurologic problems).
Hoarse or Crowing (laryngeal irritation).
XXIII. PERSONALITY AND
BEHAVIOR

Infant’s response to your

Assessment/Response to handling --

Reactions to surroundings -- Ability to pay attention to auditory or visual stimuli

during “quiet alert.” Infants should focus eyes & turn heads toward stimulus
in an attempt to prolong contact with it.

Parent-infant interaction -Eating-Sleeping Patterns

 Works Cited

McKinney, Emily Slone, 3rd Edition, 2009, pgs. 492-533, Table 22-2, pg. 1390.