Newborn Assessment I

Maternity

After the baby is stabilized & the APGAR score is assessed, a newborn head to toe assessment
is completed. We mainly look for signs & symptoms of maturity and prematurity - in order to Full Term Birth
guide the care that will be delivered.

Think of the baby as a bun in the oven or in this case a chicken that just came out of the oven.
A Full Term infant - born 37 weeks to 40 weeks is like a perfectly baked chicken breast. 37 weeks 40 weeks

The skin is opaque, & presence of vernix - that white cheesy substance, predominantly located
in the skins folds but the baby looks well balanced - not over or under - perfectly "done"!

Preterm Infant
A Preterm infant - born between 20 to 37 weeks - is like an undercooked raw chicken breast.

The baby’s skin is smooth, shiny, gooey (lots of vernix), translucent, and extremely flexible -
like undercooked dough! 20 weeks 37 weeks
This bun came out of the oven too soon! & is not done baking!

Post-Term

Post Term infant over 40 weeks gestation is like an over cooked, burned chicken breast.
The baby will be larger, more chunky and not so flexible. The skin literally appears burned
(dried, cracked & peeling). There are also deep creases on the hands/feet. 40 weeks

Phase 1 - Stabilization
According to ATI - newborn assessment & care is broken down into 3 phases: Phase 2 - Infant physical exam
Phase 3 - Routine care

Assessment Normal NOT normal Assessment Normal NOT normal

Vernix caseosa: white cheesy
Skin substance, predominantly
located in the skins folds
Lanugo: fine hair all over
the body to hold the vernix
in place
Mongolian spots: purple,
brown, gray flat discolorations
typically found on the back,
buttocks & lower extremities
Acrocyanosis:
Bluish discoloration on the
hands & feet with a pink trunk
→ Place the newborn skin-to
skin with mother NCLEX TIP
Peeling around the 3rd day
Preterm: 20 - 37 weeks Anterior: Diamond shaped Caput succedaneum: localized edema
NCLEX TIPS Fontanelles of the scalp (like a cap)
Posterior: Triangular
1. Shiny, wrinkly skin & Head Shape Cephalhematoma: localized hematoma
2. “Translucent”, very fragile, Molding: mis-shapen head resulting beneath the periosteum caused by
Smooth, red/pink skin with visible veins from pressure in the birth canal; trauma
3. Flat areolas without palpable breast buds disappears in 3 - 7 days.
4. Abundant lanugo on shoulders & back
& gooey (lots of vernix) HESI
Postterm: Over 40 weeks ATI
Cracked, dried, peeling skin (desquamation)
Cyanosis: blue, pale core REPORT TO HCP
Jaundice “yellowing of the skin” REPORT
Nevus vasculosus (strawberry hemangioma):
raised, red nodule.
Nevus flammeus (port wine stain): 3 - 7 days
pink, red, purple patch of skin, often on the face.

Assessment Normal NOT normal Assessment Normal NOT normal

Eyes open Low-set ears & flat nose bridge REPORT TO HCP Epstein’s pearls: white pearl-like cysts Assess for cleft lip or palate
Eyes, Ears Mouth on gum margins & palate NCLEX TIP
Ear stiff but pliable Eyes:
& Nose (more stiff is more mature) Ptosis of an eyelid REPORT
Milia: white papules “white heads” Cataract seen as red reflex REPORT
on the nose Jaundice Sclera within the first 24 hours
Coloboma - defect in the pupil
HCP
1

ATI Question
neonate after delivery…. Which of the following
assessment is most concerning? Cleft lip Cleft palate
Ptosis of the left eyelid