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Assessing Newborns Health Assessment Property of Susan L. Arnold, RN, MSN, ACUE Newborns Newborns and infants are a specialized population to be assessed. Newborn is the term used for a child from birth through 28 days old. Infant refers to a child between the ages of 28 day...
Assessing Newborns Health Assessment Property of Susan L. Arnold, RN, MSN, ACUE Newborns Newborns and infants are a specialized population to be assessed. Newborn is the term used for a child from birth through 28 days old. Infant refers to a child between the ages of 28 days to 1 year. The newborn makes multiple adjustments to its respiratory and circulatory systems as it adjusts to extrauterine life. Newborns are unable to communicate verbally; they communicate through behavior. The nurse must assess and interpret the newborn’s behavior to obtain an accurate assessment of the newborn’s health. Diagnostics Blood samples may be drawn from the newborn to identify disorders that may affect the health of the newborn (drawn via heel stick) Metabolic profile – errors of metabolism and blood disorders Phenylketonuria (PKU) test – check for phenylalanine (amino acid required for normal growth and development); deficiencies could cause serious neurological and intellectual disabilities Serum bilirubin level – if elevated, skin and sclera may turn yellow (jaundice) Glucose screening – some newborns are at a higher risk for hypoglycemia; SGA, LGA, premature, diabetic mothers Health History It is important to include the parent(s) in the assessment process from the moment of the newborn’s birth. The mother, parents, or primary caretaker are the primary sources for gathering information about the newborn and pregnancy history. Cultural variations among families should be taken into consideration. Use the COLDSPA mnemonic to identify attributes of a symptom. Pregnancy planned/unplanned Prenatal care Health History Begin by reviewing the perinatal history. Past medical history of mother – any diseases Hypertension – can cause decreased placental perfusion resulting in restricted fetal growth (SGA or preterm birth) Anemia – increased risk for preterm delivery and low birth weight Diabetes – LGA can cause birth trauma and newborn hypoglycemia Preterm labor (before 37 weeks) or antepartum bleeding (from 24 weeks gestation) Health History Blood type newborns born to mothers with any negative blood type or O type blood are at increased risk for jaundice. Illnesses or infectious diseases during pregnancy TORCH infections (toxoplasmosis, syphilis, varicella-zoster, parvovirus B19, rubella, cytomegalovirus, and herpes) can cross the placenta and have serious effects on the fetus. Review human immunodeficiency virus (HIV) and hepatitis status; can cross the placenta Review Group B strep, gonorrhea, and chlamydia infections; pass to the newborn during labor and delivery. Medication History Types of medications taken During pregnancy During the birth of the baby Prescription medications Herbal therapies Over-the-counter drugs Psychosocial History of Mother Smoking – during pregnancy? Smoking can lead to prematurity, low birth weight, or increased risk of sudden newborn death syndrome (SIDS). Drinking – how much, how often, during pregnancy? Drinking alcohol during pregnancy can cause fetal alcohol syndrome (FAS); facial anomalies, deafness, heart defects, developmental delays, neurological abnormalities Substance use –prescription or “street drugs”? Newborn prematurity, low birth weight, drug withdrawal Family History History of birth defects such as spina bifida (congenital neural tube defect which can affect the brain, spinal cord, spine, and meninges) or congenital heart defects History of Congenital anomalies Cardiac abnormalities Blood disorders Newborn’s Birth History Estimated due date (preterm/post term delivery) Length of rupture of membranes (risk of infection) Length of labor Medications used during labor and birth Type of delivery –vaginal, operative(c-section) Apgar score - gives a quick assessment of the newborn’s transition to extrauterine life Apgar Score Apgar score is evaluated at 1 and 5 minutes after birth. The score is based on five categories: Heart rate Respiratory rate Muscle tone Reflex irritability Skin color Preliminary Steps Area should be well lit, warm, and draft free Best place to assess a newborn is under a prewarmed radiant warmer Newborn should be completely undressed Assessing Weight Purpose: To obtain an accurate initial weight of newborn Equipment: Digital scale, gloves For all newborn assessments put on gloves if the newborn has not had an initial bath. Never leave a newborn alone on the scale. Place a receiving blanket on the scale and calibrate (zero) the scale. Ensure that the newborn is completely naked. Assessin Gently place newborn on scale, placing a hand above g the newborn to ensure safety. Weight Read and record the weight in both grams and pounds. Gently place the newborn back in the bassinet. Plot the weight on growth curve chart for gender. Assessing Weight Normal Findings Abnormal Findings Weight range for full-term Weight is < 2,500g or > newborn is 2500g-4000g 4,000g (5lbs. 8oz to 8lbs.13oz) Weight loss of >10 % in the Average weight for full-term first 3-5 days of life newborn is 3400g (7lbs. 8oz) About 10% weight loss related to decreased fluid intake and fluid loss is expected over the first 3- 4 days after delivery. Growth Charts Assessing Length Purpose: To obtain an initial length of newborn. Equipment: Measuring tape, gloves Gently place newborn supine on a flat surface Place a mark on the surface at the top of the newborn’s head Extend the newborn’s leg and make a mark at the bottom of the heel Place the newborn back in the bassinet Measure the length from the head marking to the heel marking Measure the length in inches and centimeters Plot the length on the growth curve chart for gender Assessing Length Normal Findings Abnormal Findings Lengthrange for term Length of 55cm (21 21 inches). inches) Measuring Chest Circumference Purpose: To obtain initial measurement of newborn’s chest circumference Equipment: Paper measuring tape, gloves Place tape measure across newborn’s nipple line Pull snugly upon newborn’s expiratory breath Note the measurement in inches and centimeters Chest circumference should be 1-2 cm less than head Document your findings Measuring Chest Circumference Normal Findings Abnormal Findings Ranges 30-33cm Chestcircumference (11.8-13.8 inches) is < 29cm or > 34cm. Chest Chest circumference circumference is is greater than head less than head circumference. circumference Measuring Head Circumference Purpose: To assess the newborn’s head circumference Equipment: Measuring tape, gloves Find the greatest diameter of head (occipital frontal area). Gently place the measuring tape securely around newborn’s head. Gently pull the measuring tape snugly and note the size of the head circumference in centimeters or inches. A newborn’s head circumference should be about 2 cm greater than chest circumference. Measuring Head Circumference Normal Findings Abnormal Findings Head circumference is Head circumference 33-35.5cm (12.5- 35.5cm; (1-2 14.5inches); 2cm larger cm) greater than chest than chest circumference Head is large in Microcephalic proportion to their body Macrocephalic Assessing Temperature Purpose: To assess the body’s core temperature Equipment: Digital thermometer, gloves Visualize the newborn’s axilla. Gently place the thermometer probe in the deepest part of the axilla. Gently hold the newborn’s arm in place; against their body. When thermometer registers and beeps, note the temperature. Rectal temperature is most accurate of a newborn’s core temperature, but not recommended due to health risks. Assessing Axillary Temperature Normal Findings Abnormal Findings Normal range is 36.5- Below 36.5 (97.7 F) 37.4 C (97.7- 99.3 F) indicates hypothermia and above 38.0 C (100.4 F) indicates hyperthermia Notify the healthcare provider for any abnormal temperatures Assessing Rectal Temperature Normal Findings Abnormal Findings Normal range is 36.5- Below 36.5 (97.7 F) 37.6 C (97.7- 99.7 F) indicates hypothermia and above 38.0 C (100.4 F) indicates hyperthermia Notify the healthcare provider for any abnormal temperatures Assessing Heart Rate Purpose: To assess the heart rate of the newborn Equipment: Neonatal stethoscope Watch or clock with a second hand Gloves Assessing the Heart Rate Wipe off the stethoscope with an alcohol swab Warm the stethoscope between the palms of your hands Place stethoscope on newborn’s chest, near the left nipple, at the fourth intercostal space Auscultate crisp S1 and S2 sounds Determine whether rhythm is regular or irregular Count the apical heart rate for one full minute If the newborn is sleeping, obtain the heart and respiratory rate before performing any other part of the assessment Assessing Heart Rate Normal Findings Abnormal Findings Heart rate ranges from Heartrate > 160 bpm 120-160 beats per (Tachycardia) minute (bpm) Heartrate < 100 bpm (Bradycardia) Heart murmur – abnormal sound such as whoosh or swish Cardiac arrhythmia – abnormal rhythm Notifyhealthcare provider if irregular heart rate, rhythm, or murmur Assessing the Newborn Heart Rate Normal Heart rate ranges from 120 to 160 bpm Abnormal Heart rate Tachycardia – heart rate greater than 160 bpm Bradycardia – heart rate less than 100 bpm Arrhythmia - abnormal heart rhythm Important to Note – be sure to document the activity of the newborn when assessing the heart rate; a newborn in a deep sleep may have a heart rate as low as 100 bpm, while a crying newborn may have a heart rate over 160 bpm. Assessing Respiratory Rate Purpose: To assess pulmonary ventilation Equipment: Neonatal stethoscope Watch or clock with a second hand Carefully observe the rise and fall (one breath) of the newborn’s abdomen (newborns are abdominal breathers). Newborns are obligatory nose breathers; significant distress when nasal passages are obstructed Count respirations for one full minute either by observation or auscultation with a stethoscope. Assessing Respiratory Rate Normal Findings Abnormal Findings Respiratory rate will be Apneic period > 15 seconds irregular in depth, rate and Respiratory rate of greater rhythm than 60 breaths/minute Short pauses between 5 to Retractions, grunting, nasal 10 seconds are normal flaring, stridor, rales Ranges from 30-60 Seesaw or paradoxical breaths/minute respirations where chest Chestand abdomen rise wall retracts while abdomen simultaneously rises NotifyPCP if prolonged apneic periods (> 15 seconds) with color change or prolonged tachypnea Assessing Blood Pressure Purpose: To assess circulatory blood volume as the heart contracts and relaxes Equipment: Noninvasive electronic BP device BP cuff-appropriately sized for the newborn Preferred time to obtain while the newborn is asleep BP is not routinely measured on healthy newborns. Essential measurement if the newborn is premature or has cardiac or renal disease. Assessing Blood Pressure Determine appropriate BP cuff size for the newborn - the cuff should cover two-thirds of the upper arm or upper leg. Gently restrain the limb that you are going to use for the BP by gently holding with your hand Position the BP cuff on the newborn’s extremity and wait until the newborn becomes calm. Press the button on the digital BP monitor to allow the BP measurement to begin. Continue to gently restrain the limb until the BP measurement appears on the screen. Assessing Blood PressureAbnormal Findings Normal Findings Thenormal BP range for a BPexceeding 95mmHg newborn is 50-75/30-45 mm systolic or 75 mmHg Hg at birth. diastolic in a term newborn. Normal BP for a full-term A gradient between the newborn at birth is 72/42. systolic upper and lower extremity blood pressure of > 10 mm hg should be suspicious of anomalies of the aorta. Purpose: To assess the newborn’s systems and observe for any abnormalities A portion of the assessment can be completed without rousing the newborn. The newborn can become cold General quickly. Be sure to perform the Assessm examination quickly and in a heated environment. ent Newborns are unable to shiver, ineffective thermoregulation. Tip – Swaddling the newborn or giving them a pacifier can help soothe and calm the newborn during assessment. Stand at the newborn’s side and inspect and observe the: Activity level Deep sleep General Light sleep Assessme Drowsy nt Quiet alert Active alert Crying Resting posture Muscle tone Assess the skin throughout the entire assessment: Color Pink Jaundiced (assess by pressing one finger on the newborn’s head, nose, or sternum; skin will appear General yellow when you release Assessm pressure) ent Pale Acrocyanosis – blue hands and feet (normal first 24 – 48 hours of life due to newborn being cold) Mottled-lacy pattern of dilated blood vessels; may be noted if newborn is chilled Depends on gestational age and ethnicity Post-term newborns will have peeling, dry, cracked skin. Preterm newborns will General have lanugo and vernix caseosa present. Assessme Skin color is best nt: Skin assessed by blanching the skin, the underlying color when blanched should be pink (regardless of ethnicity). Color and capillary refill is best assessed on the newborn’s sternum Normal Findings: Lanugo - fine hair covering the body (head, back, and shoulders) decreases with advancing age. General Vernix caseosa - thick Assessme cheese-like coating may be present at birth, nt: Skin especially in the folds. Milia - pearly white cysts from sebaceous glands; often on nose. Normal Findings – Birthmarks: Nevus simplex (stork bites) - capillaries close to surface of the skin. Mongolian spots - bluish-black pigmented areas; sacral area. Hemangioma - “Strawberry Mark”- harmless growth/tumor of tiny General blood vessels. Assessme Café au lait spots - permanent flat patches; tan to light brown. nt: Skin Nevus flammeus - (port-wine stain)capillary malformation just below the surface of the skin; red/purple, doesn’t blanche, permanent. Erythema toxicum - benign newborn rash, yellow/white papules/pustules with red base. General Assessme nt: Skin Mottling Acrocyanos is General Assessment: Skin Lanugo Vernix Caseosa General Assessment: Skin Milia Stork Bites General Assessment: Skin Abnormal Findings: Pathological jaundice is jaundice that appears before 24 hours of age, associated with anemia and hepatosplenomegaly. Pale color and mottled skin may indicate poor perfusion or poor thermoregulation. Central cyanosis is indicative of hypoxia, pulmonary disease, or congenital heart malformations. Petechiae can be a result of birth injury, infection, or blood disorder. Bruising due to pressure during delivery Lesions Purpose: To assess abnormalities of the Inspecti head Equipment: Gloves ng and Carefully inspect the Palpatin parts of the newborn’s head: g Head Anterior fontanel Posterior fontanel A newborn’s neck muscles are weak and cannot support the head. Inspecting and Palpating Head Standing on one side of the newborn, inspect the shape of the newborn’s head for abnormal deviations. Gently palpate the anterior fontanel. Gently palpate the cranial suture line from the anterior fontanel to the posterior fontanel; may be separated, approximated, or overriding. Gently palpate for the posterior fontanel. Inspecting and Palpating Head Normal Findings Abnormal Findings Normocephalic and Bulgingor depressed symmetric fontanels Anteriorfontanel “soft spot” Caput succedaneum (fetal should feel soft and flat scalp edema) (usually closes by 18 mos.) Cephalohematoma Posterior fontanel-may be (unilateral) nonpalpable (usually closes Hydrocephalus by 2 mos.) Sutures may be separated, approximated or overriding Shapeof head: Round or molding Purpose: To assess deviations and abnormalities of the eyes, ears, nose and mouth Inspecti Equipment: Gloves, ng the penlight Face Inspect the face for symmetry; compare both sides. Inspecting the Face Inspect the following parts of the eyes Color of the eyes Sclera for color Yellow sclera – first sign of jaundice Eye color Conjunctiva Eyelid edema may be present due to prolonged pushing during delivery Presence of yellow or white discharge may indicate a clogged tear duct or conjunctivitis Phototherap y for Jaundice Assessing the Nose Inspect the nose for patency. Occlude the left naris (nostril) with one finger. Observe for flaring of the right naris for cyanosis or asphyxia. Occlude the right naris with one finger. Observe for flaring of the left naris for cyanosis or asphyxia. Note: newborns are obligate nose breathers; they do not develop the response of opening the mouth due to a nasal obstruction for several weeks after birth Nasal Flaring Inspect the ears for size and position in relation to the eyes Determine the position of the ears in relation to the eyes; draw an imaginary line from the inner canthus of the eye outward. Assessin Clap next to the newborn’s right g the ear; observe to see if the newborn turns its head toward Ears the direction of sound. Clap next to the newborn’s left ear; observe to see if the newborn turns its head toward the direction of sound. The position of the eustachian tube and its proximity to the nasopharynx place the Assessin newborn at a higher risk for developing ear infections. g the The eustachian tube is short, Ears wide, and horizontal. Teach caregivers to not feed the newborn in a flat lying position. Assessing the Mouth Using a penlight, inspect the inside of the newborn’s mouth. Gently insert a gloved index finger into the newborn’s mouth with the pad of the index finger and palpate for a smooth, uninterrupted palate. Gently palpate the hard and soft palate to determine whether they are intact. Assess the following reflexes: Rooting Sucking Gag Assessing Face, Eyes, Nose, Mouth Normal Findings: Face is symmetrical. Eyes are symmetrical. Nose is patent bilaterally. Ears-normally placed, no pits or tags. Mouth-mucous membranes pink and moist. Hard and soft palates intact. Epstein’s pearls are small cysts on the roof of the mouth formed when the palate fused. Rooting, sucking, and gag reflex are present. Assessing Face, Eyes, Nose, Mouth Abnormal Findings: Face is asymmetrical, often because of position in utero Facial or head injuries if forceps or other instruments used during delivery. Eyelids: edema with prolonged pushing; subconjunctival hemorrhage Nose: nasal flaring, nasal discharge, asymmetry of the nose Ears: low set ears, preauricular pits or skin tags Mouth: mucous membranes dry, cyanotic, cleft hard or soft palate, natal teeth Absent suck, rooting or gag reflex Observe newborn’s mouth when crying for facial paralysis/asymmetry which can be caused by pressure from maternal pelvis or forceps during delivery. Normal Findings: Neck is short, thick, and without webbing Assessin Full ROM g the Abnormal Findings: Neck Webbing – skin folds appear as loose folds of skin May indicate Down syndrome or Turner syndrome Assessing Capillary Refill Purpose: To assess peripheral perfusion. Equipment: Watch with a second hand, gloves Position the newborn in the supine position. Using the finger pad of the index finger, gently press down and blanche the skin on the newborn’s sternum. Note the time in seconds that it takes for the blanched skin to return to a normal color. Normal capillary refill - less than 3 seconds Assessing Capillary Refill Normal Findings Abnormal Findings Capillary refill < 3 Poor perfusion if capillary seconds refill is > 3 seconds Assessing Respiratory System Purpose: To assess pulmonary perfusion Equipment: Neonatal stethoscope, gloves Place newborn in supine position and observe the clavicular, substernal, and the intercostal areas of chest. Closely observe the rise and fall of the newborn’s chest while breathing and count the number of breaths in one minute. Assessing Respiratory System Using the diaphragm of the neonatal stethoscope, auscultate the anterior and posterior lungs. Place stethoscope on newborn’s anterior chest bilaterally and listen for equality of bilateral breath sounds from the base to the apex of the lungs. Gently roll the newborn to its side, place the stethoscope on newborn’s posterior chest bilaterally and listen for equality of bilateral breath sounds from the base to the apex of the lungs Assessing Respiratory System Abnormal Findings Normal Findings Thoracic area -no Substernal, intercostal or retractions observed suprasternal retractions Diaphragmatic Breath sounds are respirations are present; decreased on one side rate between 30-60 bpm Crackles are heard Breath sounds are clear and equal bilaterally Respirator y Distress Purpose: To assess and screen for fractured clavicles Place the newborn in the supine position and inspect the shape of the newborn’s chest. Inspecti Draw an imaginary line down the center ng and of the newborn’s chest and observe for Palpatin symmetry of both sides. g Chest Using your index finger pads, gently palpate each clavicle from the shoulder to the sternum; listen and feel for crepitus, edema, or a noticeable step-off. Inspecting and Palpating Chest Inspect breasts for symmetry. Inspect the number of nipples; observe for number of nipples along the nipple line. Using the finger pads of the 2nd and 3rd fingers, gently palpate the breasts for size of breast buds. Gently squeeze each breast bud with the gloved finger pads of your fingertips to assess for galactorrhea, “witches' milk” (milky white discharge caused by high maternal estrogen levels; considered normal) Inspecting and Palpating Chest Normal Findings Abnormal Findings Chest is symmetrical Asymmetrical chest Clavicles are intact crepitus on one or more Breasts clavicles have two well- formed, symmetrical breast Breasts-supernumerary buds nipples are present Breast bud Engorged breast bud Approximately 6mm in diameter Galactorrhea Auscultating Bowel Sounds Assess peristalsis with newborn in supine position Auscultate bowel sounds before palpation; palpation can trigger increased bowel sounds Auscultate in all four quadrants Bowel sounds should be present 1-2 hours after birth Absent or hypoactive bowel sounds may indicate intestinal obstruction Inspecting and Palpating Abdomen Place newborn in supine position Assess symmetry of the abdomen from side to side noting the shape Inspect the umbilical cord for number of vessels, color, consistency, drainage, odor, signs of infection Palpate the newborn’s abdomen prior to feeding or 2 to 3 hours after Using the finger pads of the second and third fingers, gently palpate all four quadrants Inspecting and Palpating Abdomen Normal Findings Abnormal Findings Abdomen symmetrical Abdomen asymmetrical Shaperound, dome Shape scaphoid or shaped, nondistended distended Umbilicalcord has two Umbilicalcord has one arteries and one vein artery and one vein present; no odor, no Signs of infection drainage, no signs of Abdomen tense and firm redness or inflammation with masses noted Abdomen should be soft, nontender, no masses palpated Pain Assessment Purpose: To assess pain level Equipment: Neonatal stethoscope Watch or clock with a second hand Newborns cannot communicate pain verbally. Pain is identified by observing physiologic and behavioral changes in the newborn. Observe for crying, grimacing, changes in wake-sleep status, and attention/communication Pain Scales Neonatal Infant Pain Scale Neonatal Facial Coding System Pain Assessment – Newborn Infant Pain Scale Assess the newborn’s body for skin color Assess the newborn’s behavioral cues: Facial expression Cry Breathing patterns Body Movements (arms & legs) State of arousal Pain Assessment Normal Findings Abnormal Findings Color is pink Cry:whining, intense, urgent Facial expressions: face cry, high-pitched, unable to be appears relaxed soothed Facial expressions: frowning, Body movements: normal tone and posture gaze aversion Bodymovements: rigid, Stateof arousal: quiet, sleeping, calm hyperextended neck, flailing, thrashing, frantic behavior State of arousal: hyper alert Purpose: To assess newborn’s hydration status. Assess whether the newborn is breastfed or formula-fed. Assess the amount of milk taken. Assessin Breastfed: number of minutes per feeding g Formula-fed: number of ounces/per feeding Hydratio Assess the frequency of feeding n Assess the toleration of feeding Assess for weight gain/loss Assess the voiding amount and pattern by: The number of wet diapers a newborn has in a 24-hour period The number of stools a newborn has in a 24-hour period Assessing Hydration Normal Findings Breast-fed newborn Formula-fed newborn Nurseswell on at least Feeds approximately 2 oz one breast every 1.5- 3 of formula every 3-4 hours hours Appears satiated after Presence of 6-8 wet Presence of 6-8 wet diapers a day diapers a day Has at least 2-3 stools/day Has at least 2-3 stools/day Stool will be a shade of Stool will be loose, yellow brown, soft, pasty and seedy Assessing Hydration Abnormal Findings Newborn feeding is less than 6 times/day Vomits large amounts after feedings Less than 6 wet diapers in a 24-hour period Presence of uric acid crystals (pink to dark pink staining in the diaper related to concentrated urine) 0-1 stools/day may indicate constipation Depressed fontanels Dry sticky mucus membranes Reduced or absence of tears Newborn Reflexes Reflexes that are present in all normal newborns; most disappear within a few months after birth. Absence of a reflex at birth or persistence of a reflex beyond expected date of disappearance could indicate a CNS dysfunction. Rooting Sucking Palmer grasp Plantar grasp Tonic Neck Moro (startle) Babinski Stepping Healthy People 2030 Goal: Improve the Health and Safety of newborns/Infants Always place your newborn/infant flat on the back to sleep in the crib. Nothing else in the crib. Goal: Increase the proportion of newborns who are breastfed You are assessing a newborn’s skin. What is a true statement about a newborn’s skin? A. All newborn’s have thin transparent skin. Preterm Question B. newborns have dry, flaky skin. C. Skin varies dependent on length of pregnancy. D. A newborn’s skin is thick and moist. Answer Correct answer: C The newborn’s skin is not fully developed at birth and matures with age. The skin will vary depending on the length of pregnancy. You are taking a health history. What is the first history that you should document? Question A. Medication B. Family C. Psychosocial D. Prenatal Correct answer: D Begin by reviewing the prenatal history to Answer identify whether the pregnancy was normal or with health risks or complications. You are palpating a newborn’s head for the first time. You palpate overriding sutures. What is your next step? A. Call the health care provider immediately Assess for Question B. dehydration C. Notify the mother of this abnormal finding D. Continue the assessment and palpate the posterior fontanels Correct answer: D Answer This is a normal finding related to molding of the head. You should continue the head assessment and palpate the posterior fontanel. You are preparing to weigh a newborn for the first time. The newborn has not had a bath. Put in order the sequence of the assessment. A. _____Document the Question weight B. _____Put a receiving blanket on scale C. _____Calibrate the scale D. _____Put on gloves E. _____Gently place the newborn on the scale Correct answer order: D, B, C, A, E D. _1_ Put on gloves B. _2_ Put a receiving blanket on scale Answer C. _3_ Calibrate the scale A. _4_ Gently place the newborn on the scale E. _5_ Document the weight
