Newborn Physical Exam and Skin Assessment

Physical Examination of the Newborn

• It's important to know normal newborn characteristics and behaviors
• Identify abnormal findings and potential problems as a nurse
• Nurses are often the first professionals to physically examine and initiate care for newborns
• APGAR scores are assessed at 1-minute and 5-minute intervals
• Observe the infant for position, sleep/wake cycle, skin color, and respiratory pattern before tactile stimulation
• Vital signs should be checked
• Measurements include length, head, and chest circumference

Skin Assessment

• Acrocyanosis is the bluish color of hands and feet due to immature peripheral circulation, typically present in the first 24-48 hours after birth
• Lanugo is the fine, downy hair found on newborns
• Vernix caseosa is the white protective coating on the newborn's skin

Birthmarks, Rashes, and Skin Lesions

• Hemangiomas are newly formed capillaries in the dermal and subdermal layers
• Nevus flammeus is a port wine stain that involves dilated skin capillaries
• Nevus simplex is a stork bite or angel kiss
• Melanocytic nevi, or moles, are uncommon in newborns
• Erythema toxicum neonatorum is a newborn rash with macules, papules, or vesicles on the body
• Acne neonatorum involves clogged hair follicles
• Milia are occluded sebaceous glands
• Dermal melanosis, or mongolian spots, involves trapped melanocytes
• Abnormal skin assessment findings should be noted

Head Assessment

• Note the appearance, shape, circumference, and suture lines of the head
• Cephalohematoma is swelling on the head that does not cross suture lines
• Caput succedaneum is swelling of the scalp
• Fontanels, or soft spots, are fibrous membranes between the bones of the cranium
• Note any abnormal head assessment findings

Eye Assessment

• Examine the eyes and eyelids for symmetry
• Note any abnormal eye assessment findings

Ear Assessment

• Note the ear size, shape, and location
• Note any abnormal ear assessment findings

Nose Assessment

• The nose should be midline with symmetrical nares
• Clear nasal drainage is expected
• Note any abnormal nose assessment findings

Mouth Assessment

• Inspect lips, mouth, tongue, palate, and gums
• Note any abnormal mouth assessment findings

Chest Assessment

• Observe the chest for shape and symmetry of movement
• Gynecomastia, or breast enlargement, results from maternal hormones
• Note any abnormal chest assessment findings

Respiratory System Assessment

• Assess breathing effort, chest movement, and auscultation of lungs
• Periodic breathing is normal
• Retractions involve skin pulling around ribs and sternum with difficult inhalation
• Apnea is the cessation of breathing for more than 20 seconds
• Document any abnormal respiratory assessment findings

Cardiovascular System Assessment

• Assess heart sounds using APTM, "All Physicians Take Money" to remember the valve locations
• Assess peripheral pulses for quality and equality
• Assess capillary refill
• Note any abnormal cardiovascular assessment findings

Abdomen and Gastrointestinal Assessment

• Observe the shape, contour, and movement of the abdomen
• Listen for bowel sounds

Genitourinary System Assessment

• In females, inspect genitalia for placement of labia and urinary meatus
• Pseudomenstruation involves mucus and blood-tinged vaginal discharge
• In males, inspect the penis to ensure it’s midline and straight, with the urethral opening midline
• Assess urinary output
• Note any ambiguous genitalia

Neurologic System Assessment

• The newborn neurologic system is immature at birth, so jerking and twitching are normal
• Assess reflexes (see Table 15.2)
• Note any abnormal neurological assessment findings

Musculoskeletal System Assessment

• Evaluate resting posture
• Assess hips for dysplasia using Ortolani and Barlow maneuvers
• Assess the spinal cord and back for curvatures and asymmetry
• Document any abnormal musculoskeletal assessment findings

Pain Assessment

• Use the Neonatal Infants Pain Scale (NIPS), see Table 15.3

Clicker Check - Assessing Heart Sounds

• Erb’s point is located at the left lower sternal border (LLSB) in the third intercostal space
• Erb’s point is good for evaluating the S2 heart sound
• The aortic valve is assessed by placing the stethoscope at the second intercostal space to the right of the sternum
• The pulmonic valve is assessed by placing the stethoscope at the second intercostal space to the left of the sternum

Medications for Newborns

• Vitamin K
• Erythromycin ointment
• Hepatitis B vaccine

Estimating Gestational Age

• Gestational age estimation is completed on preterm, post-term, babies of diabetic mothers, mothers with no prenatal care, and babies weighing less than 2,500 g or more than 4,000 g
• Preterm infants are born before 37 weeks
• Post-term infants are born after 42 weeks
• The Ballard tool is used

Bathing a Newborn

• Bathing removes blood and body fluids
• Bathing options: Sponge, small tub, large tub or immersion bathing, swaddling immersion bathing

Newborn Screening

• Newborns are screened for genetic, metabolic, and endocrine disorders
• Newborns are screened for infectious diseases, hearing loss, and congenital heart disease
• A blood specimen is collected during screening

Newborn Screening - Heart and Hearing

• Congenital heart defect screening checks for critical congenital heart defects (CCHD)
• Heart defect screening is performed on infants 24 hours or older
• Pulse oximetry probes are used in congenital heart defect screening
• Hearing screens: Automated otoacoustic emission test (AOAE), Automated auditory brainstem response (AABR), and Brainstem auditory evoked response (BAER)

Discharge Teaching - Safety

• Focus on safety when teaching parents
• Teach about the use of the bulb syringe
• Teach car seat safety

Discharge Teaching - Care

• Teach about trimming nails, diaper rash, and umbilical cord care
• Discuss circumcision, which is the surgical removal of the end of the foreskin on the penis
• Discuss feeding schedules and elimination patterns
• Education on proper positioning and holding techniques, clothing, swaddling, sponge bathing, and skin care
• Education on follow-up after discharge, following Patient Teaching Guidelines

Clicker Check - First Bath

• Sponge bathing should be done until the umbilical cord falls off, and if applicable, the circumcision site is healed
• Parents may give the baby a bath at that point
• The amount of time for this to occur varies based on the newborn, so no set amount of time from discharge can be determined