Neonatal Assessment: Vital Signs & Distress

• Neonatal assessment encompasses describing components, anatomical and physiological changes during adaptation, clinical assessments, and care interventions needed for the neonate
• It also includes identifying normal physiological variations and describing as well as assessing neonate behavior

Vital Signs

• Normal respiratory rate is 30-60 breaths per minute and counted for a full minute
• Auscultate for a full minute through chest and abdomen observation
• Normal heart rate is 110-160 beats per minute and listen for a full minute
• Murmurs are typically physiologic and resolve in early infancy
• Further assessment of murmurs is rarely indicated unless there are associated cardiac or respiratory difficulties
• Normal temperature ranges from 97.7-100.4°F (36.5-38.0°C), acknowledging institutional variations
• Maintaining warmth during assessment is important
• Postpone bathing

Signs of Respiratory Distress

• Central cyanosis is abnormal, indicated by bluing of the lips and chest
• Transient cyanosis while crying is not uncommon after birth
• Apnea lasting 20 seconds or more requires concern
• Brief apnea periods without other distress signs are normal
• Apnea over 20 seconds could indicate sepsis, hypothermia, or hypoglycemia
• Tachypnea, over 60 breaths per minute, is abnormal and may indicate respiratory distress syndrome or fluid in the lungs
• Can also indicate infection or cardiac/metabolic issues
• Retractions indicate reduced lung pressure because of upper airway occlusion
• Grunting involves a partially closed glottis, increasing lung pressure for better oxygen diffusion

APGAR Scoring

• Appearance includes assessing skin color, with scores ranging from blue/pale to completely pink
• Pulse assesses heart rate, with scores for no pulse, below 100, and above 100 bpm.
• Grimace evaluates reflex irritability, with scores for no response, grimace, and cry/cough/sneeze
• Activity assesses muscle tone, with scores for limp, some flexion, and active movement
• Respiration evaluates breathing effort, with scores for no respirations, weak/slow, and strong cry

Immediate Interventions

• Eye prophylaxis with Erythromycin Sulfate Ointment is mandatory in the U.S.
• Prophylaxis prevents ophthalmia neonatorum, or eye inflammation from gonorrhea or chlamydia
• Vitamin K prophylaxis prevents hemorrhagic disease, as newborns lack vitamin K in their sterile intestines
• Hepatitis B vaccine is administered via IM injection
• Hepatitis B Immunoglobulin can also be administered

Skin Assessment

• Inspect skin throughout the exam
• Vernix caseosa is a white, cheese-like substance and a product of sebaceous glands
• Vernix is a protective skin barrier which covers the body after 35 weeks
• Jaundice assessment involves blanching the skin
• Jaundice occurs first in sclera and face, progressing down the chest, abdomen, and extremities
• Transcutaneous bilirubin measurements can be used for assessment
• Acrocyanosis, or bluish coloring of extremities, is normal

Additional Skin Assessments

• Slate grey nevi resemble bruising and should be documented
• Café au lait spots may be normal depending on the quantity
• Erythema toxicum, also called "newborn rash" or "newborn acne", is benign and resolves without treatment
• Erythema presents as erythematous macules, papules and vesicles
• Nevi simplex or "stork bites" are common at the nape of the neck, eyelids, and glabella between the eyebrows, and usually fade within 2 years

Additional Skin Assessments

• Nevus flammeus, also known as a "port-wine stain," is a non-blanchable discoloration of the skin
• Typically flat and pink at birth but darkens and becomes textured over time
• Nevus vascularis also known as "strawberry hemangioma," is an area on the skin that is raised and sharply demarcated
• It may be present at birth or appear in the first several weeks postpartum
• Lanugo is a thin hair that covers the body between 20-28 weeks of gestation

Milia

• These are distended, small, white sebaceous glands
• They are usually found around the mouth, cheeks, nose, and chin

Head Assessment

• Hair should be fine and silky
• There should be facial symmetry
• Head circumference should be taken at the fullest part of the occiput, above the eyebrows

Ear Assessment

• Low placement of ears may indicate congenital abnormalities
• Incomplete cartilage formation correlates with prematurity
• A failed hearing test during the newborn period calls for further assessment after discharge

Mouth Assessment

• All structures should be symmetric, intact, moist, and have a pink color
• Epstein pearls are a common benign finding
• Cleft lip and palate signal neural tube defects

Neck Assessment

• Asses for flexibility, movement and bruising
• Torticollis is a side twisted neck condition, usually resolves over time
• Intact clavicles assessed via palpation and palpated for crepitus

Abdomen Assessment

• Bowel sounds should be present
• Abdomen should be soft, round, and non-distended
• Umbilical stump should be white or gray and odorless
• Drainage and redness around the cord are concerns for infection

Umbilical Cord Assessment

• The umbilical cord may be green-tinged if meconium is present
• The normal umbilical cord has 2 arteries which are muscular, small, tight, and thick-walled
• It has 1 vein, which is also characterized by flaccid walls and larger in size

Genitalia: Male

• The urinary meatus placement should be assessed
• Hypospadias & epispadias may occur independently or together with other congenital defects
• Both testes should be palpable within the scrotum
• First void should occur within the first 24 hours

Genitalia: Female

• The labia majora should cover labia minora and clitoris
• There may be a white or blood-tinged discharge, aka "pseudo-menses"
• Urethral placement above or on top of clitoris instead of beneath also suggests ambiguous genitalia

Anus/ Bowel Movement

• There should be a first bowel movement expected within 24 hours
• There needs to be an assessment of anal patency
• An imperforate anus requires urgent evaluation

Reflexes

• Rooting reflex
• Suck reflex
• Extrusion reflex
• Palmar/ plantar grasp reflex
• Tonic neck (fencing)
• Moro/ Startle reflex
• Babinksi reflex
• Stepping reflex

Discharge Testing

• Critical Congenital Heart Disease (CCHD) screening
• Around 300 infants are discharged with unrecognized CCHD
• Test is done around 24 hours of age
• Newborn screen is mandated by U.S. Law
• Hearing Screen
• Transcutaneous Bilirubin