NCMA217 Care of the Mother, Child, Adolescent Well-being PDF, AY 2024-2025

NCMA217: CARE OF THE MOTHER, CHILD & ADOLESCENT (WELL- BEING) THE NEWBORN A.Y. 2024-2025 | First Term | Prelims Doc. CA Garcia CONTENT...

NCMA217: CARE OF THE MOTHER, CHILD & ADOLESCENT (WELL- BEING) THE NEWBORN A.Y. 2024-2025 | First Term | Prelims Doc. CA Garcia CONTENT VITAL SIGNS I. Week 9 (status: editing in progress) TEMPERATURE  The temperature of newborns is about 99° F (37.2° VITAL STATISTICS C) at birth because they have been confined in an internal body organ. The temperature falls almost WEIGHT immediately to below normal because of heat loss and immature temperature regulating mechanisms.  The birth weight of newborns varies depending on o Insulation, an efficient means of conserving the racial, nutritional, intrauterine, and genetic heat in adults, is not effective in newborns factors that were present during conception and because they have little subcutaneous fat to pregnancy. The weight in relation to the gestational provide insulation. age should be plotted on a standard neonatal o Shivering, a means of increasing metabolism graph, this way helps identify newborns who are at and thereby providing heat in adults, is rarely risk because of their small size. seen in newborns. o The average birth weight (50th percentile) for a o Brown fat, a special tissue found in mature (US) mature female newborn is 3.4 kg (7.5 newborns, apparently helps to conserve or lb); for a mature male newborn, it is 3.5 kg produce body heat by increasing metabolism. (7.7 lb). Newborns of other races weigh Newborns exposed to cool air tend to kick and approximately 0.5 lb less. cry to increase their metabolic rate and  Birth weight exceeding 4.7 kg (10 lb) is unusual, but produce more heat. This reaction, however, weights as high as 7.7 kg (17 lb) have been also increases their need for oxygen and their documented. If a newborn weighs more than respiratory rate increases. An immature 4.7kg, the baby is said to be macrosomic and a newborn with poor lung development has trouble making such an adjustment. maternal illness, such as diabetes mellitus, must be o Drying and wrapping newborns and placing suspected. Second-born children usually weigh them in warmed cribs, or drying them and more than first-born. Birth weight continues to placing them under a radiant heat source, are increase with each succeeding child in a family. excellent mechanical measures to help conserve heat. In addition, placing a newborn LENGTH against the mother’s skin and then covering the newborn with a blanket helps to transfer heat  The average birth length (50th percentile) of a from the mother to the newborn; this is termed mature female neonate is 53 cm (20.9 in). For skin-to-skin care. mature males, the average birth length is 54 cm (21.3 in). The lower limit of normal length is PULSE arbitrarily set at 46 cm (18 in). Although rare, babies with lengths as great as 57.5 cm (24 in) have been  The heart rate of a fetus in utero averages 120 to reported. 160 beats per minute (bpm). Immediately after birth, as the newborn struggles to initiate HEAD CIRCUMFERENCE respirations, the heart rate may be as rapid as 180 bpm. Within 1 hour after birth, as the newborn  In a mature newborn, the head circumference is settles down to sleep, the heart rate stabilizes to an usually 34 to 35 cm (13.5 to 14 in). A mature average of 120 to 140 bpm. newborn with a head circumference greater than 37  A newborn’s heart rate is always determined by cm (14.8 in) or less than 33 cm (13.2 in) should be listening for an apical heartbeat for a full minute, carefully assessed for neurologic involvement, rather than assessing a pulse in an extremity. although occasionally a well newborn falls within these limits. Head circumference is measured with RESPIRATION a tape measure drawn across the center of the forehead and around the most prominent portion of  The respiratory rate of a newborn in the first few the posterior head. minutes of life may be as high as 80 breaths per minute. CHEST CIRCUMFERENCE o Respiratory rate can be observed most easily by watching the movement of a  The chest circumference in a term newborn is about newborn’s abdomen, because breathing primarily involves the use of the diaphragm 2 cm (0.75 to 1 in) less than the head and abdominal muscles. circumference. This is measured at the level of the nipples. If a large amount of breast tissue or edema BLOOD PRESSURE of breasts is present, this measurement will not be accurate until the edema has subsided. Historillo, Santia Jumel P. 1 of 9 THE NEWBORN NCMA217  The blood pressure of a newborn is approximately pressure of vaginal birth. Additional fluid is 80/46 mm Hg at birth. By the 10th day, it rises to quickly absorbed by lung blood vessels about 100/50 mm Hg. and lymphatics after the first breath.  Blood pressure tends to increase with crying (and a o Once the alveoli have been inflated with a newborn cries when disturbed and manipulated by first breath, breathing becomes much such procedures as taking blood pressure). A easier for a baby, requiring only about 6 to Doppler method may be used to take blood 8 cm H2O pressure. Within 10 minutes pressure. after birth, most newborns have established a good residual volume. PHYSIOLOGIC FUNCTION o A newborn who has difficulty establishing respirations at birth should be examined CARDIOVASCULAR SYSTEM closely in the postpartal period for a cardiac murmur or other indication that he or she still has patent fetal cardiac  Changes in the cardiovascular system are structures, especially a patent ductus necessary after birth because now the lungs must arteriosus. oxygenate the blood that was formerly oxygenated by the placenta. When the cord is clamped, a GASTROINTESTINAL SYSTEM neonate is forced to take in oxygen through the lungs. As the lungs inflate for the first time, pressure decreases in the pulmonary artery (the artery  Although the gastrointestinal tract is usually sterile leading from the heart to the lungs). This decrease at birth, bacteria may be cultured from the intestinal in pressure plays a role in promoting closure of the tract in most babies within 5 hours after birth and ductus arteriosus, a fetal shunt. As pressure from all babies at 24 hours of life. Most of these increases in the left side of the heart from increased bacteria enter the tract through the newborn’s blood volume, the foramen ovale between the two mouth from airborne sources. Others may come atria closes because of the pressure against the lip from vaginal secretions at birth, from hospital of the structure (permanent closure does not occur bedding, and from contact at the breast. for weeks). With the remaining fetal circulatory Accumulation of bacteria in the gastrointestinal tract structures (umbilical vein, two umbilical arteries, is necessary for digestion and for the synthesis of and ductus venosus) no longer receiving blood, the vitamin K. blood within them clots, and the vessels atrophy o The first stool of a newborn is usually passed over the next few weeks. within 24 hours after birth. It consists of o The hematocrit is between 45% and 50%. meconium, a sticky, tarlike, blackish-green, A newborn also has an elevated red blood odorless material formed from mucus, vernix, cell count, about 6 million cells per cubic lanugo, hormones, and carbohydrates that millimeter. Once proper lung oxygenation accumulated during intrauterine life. If a has been established, the need for the newborn does not pass a meconium stool by high red cell count diminishes. Therefore, 24 to 48 hours after birth, the possibility of within a matter of days, a newborn’s red some factor such as meconium ileus, cells begin to deteriorate. Bilirubin is a imperforate anus, or volvulus should be byproduct of the breakdown of red blood suspected. cells. An indirect bilirubin level at birth is 1 o About the second or third day of life, newborn to 4 mg/100 mL. Any increase over this stool changes in color and consistency, amount reflects the release of bilirubin as becoming green and loose. This is termed excessive red blood cells begin their transitional stool, and it may resemble breakdown. diarrhea to the untrained eye. By the fourth day o A newborn has an equally high white blood of life, breastfed babies pass three or four light cell count at birth, about 15,000 to 30,000 yellow stools per day. They are sweet-smelling, cells/mm3. Values as high as 40,000 because breast milk is high in lactic acid, which cells/mm3 may be seen if the birth was reduces the amount of putrefactive organisms stressful. in the stool. A newborn who receives formula usually passes two or three bright yellow stools RESPIRATORY SYSTEM a day. These have a slightly more noticeable odor, compared with the stools of breastfed babies.  A first breath is a major undertaking because it requires a tremendous amount of pressure (about URINARY SYSTEM 40 to 70 cm H2O). It is initiated by a combination of cold receptors; a lowered partial pressure of oxygen (PO2), which falls from 80 to as low as 15 mm Hg  The average newborn voids within 24 hours after before a first breath; and an increased partial birth. A newborn who does not take in much fluid for carbon dioxide pressure (PCO2), which rises as the first 24 hours may void later than this, but the high as 70 mm Hg before a first breath. 24-hour point is a good general rule. Newborns who o All newborns have some fluid in their lungs do not void within this time should be examined for from intrauterine life that will ease the the possibility of urethral stenosis or absent kidneys surface tension on alveolar walls and or ureters. allows alveoli to inflate more easily than if o A single voiding in a newborn is only about 15 the lung walls were dry. About a third of mL and may be easily missed in a thick diaper. this fluid is forced out of the lungs by the Specific gravity ranges from 1.008 to 1.010. Historillo, Santia Jumel P. 2 of 9 THE NEWBORN NCMA217 The daily urinary output for the first 1 or 2 days SWALLOWING REFLEX is about 30 to 60 mL total. By week 1, total daily volume rises to about 300 mL. The first  The swallowing reflex in a newborn is the same as voiding may be pink or dusky because of uric in the adult. Food that reaches the posterior portion acid crystals that were formed in the bladder in of the tongue is automatically swallowed. Gag, utero; this is an innocent finding. cough, and sneeze reflexes also are present in newborns to maintain a clear airway in the event IMMUNE SYSTEM that normal swallowing does not keep the pharynx free of obstructing mucus.  Because they have difficulty forming antibodies against invading antigens until about 2 months of EXTRUSION REFLEX age, newborns are prone to infection. This inability to form antibodies is the reason that most  A newborn extrudes any substance that is placed immunizations against childhood diseases are not on the anterior portion of the tongue. This protective given to infants younger than 2 months of age. reflex prevents the swallowing of inedible Newborns do have some immunologic protection, substances. It disappears at about 4 months of age. because they are born with passive antibodies Until then, the infant may seem to be spitting out or (immunoglobulin G) from their mother that crossed refusing solid food placed in the mouth. the placenta. In most instances, these include antibodies against poliomyelitis, measles, PALMAR GRASP REFLEX diphtheria, pertussis, chickenpox, rubella, and tetanus. Newborns are routinely administered hepatitis B vaccine during the first 12 hours after  Newborns grasp an object placed in their palm by birth to protect against this disease. closing their fingers on it. Mature newborns grasp so strongly that they can be raised from a supine NEUROMUSCULAR SYSTEM position and suspended momentarily from an (UNDER PHYSIOLOGIC FUNCTION) examiner’s fingers. This reflex disappears at about 6 weeks to 3 months of age. A baby begins to grasp Mature newborns demonstrate neuromuscular function by meaningfully at about 3 months of age. moving their extremities, attempting to control head movement, exhibiting a strong cry, and demonstrating PLANTAR GRASP REFLEX newborn reflexes. Limpness or total absence of a muscular response to manipulation is never normal and suggests  When an object touches the sole of a newborn’s narcosis, shock, or cerebral injury. foot at the base of the toes, the toes grasp in the same manner as do the fingers. This reflex BLINK REFLEX disappears at about 8 to 9 months of age in preparation for walking. However, it may be present  A blink reflex in a newborn serves the same during sleep for a longer period purpose as it does in an adult—to protect the eye from any object coming near it by rapid eyelid STEP WALK-IN-PLACE REFLEX closure. It may be elicited by shining a strong light such as a flashlight or an otoscope light on an eye.  Newborns who are held in a vertical position with A sudden movement toward the eye sometimes can their feet touching a hard surface will take a few elicit the blink reflex. quick, alternating steps. This reflex disappears by 3 months of age. By 4 months, babies can bear a ROOTING REFLEX good portion of their weight unhindered by this reflex.  If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the head in TONIC NECK REFLEX that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows  When newborns lie on their backs, their heads her breast to brush the newborn’s cheek, the reflex usually turn to one side or the other. The arm and makes the baby turn toward the breast. the leg on the side toward which the head turns extend, and the opposite arm and leg contract. If SUCKING REFLEX you turn a newborn’s head to the opposite side, he or she will often change the extension and  When a newborn’s lips are touched, the baby contraction of legs and arms accordingly. This is makes a sucking motion. The reflex helps a also called a boxer or fencing reflex, because the newborn find food: when the newborn’s lips touch position simulates that of someone preparing to box the mother’s breast or a bottle, the baby sucks and or fence.It may signify handedness. The reflex so takes in food. The sucking reflex begins to disappears between the second and third months of diminish at about 6 months of age. It disappears life. immediately flex disappears at about the sixth week of life. MORO REFLEX  A Moro (startle) reflex can be initiated by startling a newborn with a loud noise or by jarring the Historillo, Santia Jumel P. 3 of 9 THE NEWBORN NCMA217 bassinet. The most accurate method of eliciting TOUCH the reflex is to hold newborns in a supine position and allow their heads to drop backward about 1  The sense of touch is also well developed at birth. inch. In response to this sudden head movement, Newborns demonstrate this by quieting at a they abduct and extend their arms and legs. Their soothing touch and by sucking and rooting reflexes, fingers assume a typical “C” position. It is strong which are elicited by touch. They also react to for the first 8 weeks of life and then fades by the painful stimuli. end of the fourth or fifth month, at the same time an infant can roll away from danger. TASTE BABINSKI REFLEX  A newborn has the ability to discriminate taste, because taste buds are developed and functioning  When the sole of the foot is stroked in an inverted even before birth. A fetus in utero, for example, will “J” curve from the heel upward, a newborn fans the swallow amniotic fluid more rapidly than usual if toes (positive Babinski sign) (Fig. 18.8). This is in glucose is added to sweeten its taste. The contrast to the adult, who flexes the toes. This swallowing decreases if a bitter flavor is added. A reaction occurs because nervous system newborn turns away from a bitter taste such as salt development is immature. It remains positive (toes but readily accepts the sweet taste of milk or fan) until at least 3 months of age, when it is glucose water. supplanted by the downturning or adult flexion response. SMELL MAGNET REFLEX  The sense of smell is present in newborns as soon as the nose is clear of lung and amniotic fluid.  If pressure is applied to the soles of the feet of a  Newborns turn toward their mothers’ breast partly newborn lying in a supine position, he or she out of recognition of the smell of breast milk and pushes back against the pressure. This and the two partly as a manifestation of the rooting reflex. Their following reflexes are tests of spinal cord integrity. ability to respond to odors can be used to document alertness. CROSSED EXTENSION REFLEX APPEARANCE OF A NEWBORN  If one leg of a newborn lying supine is extended and the sole of that foot is irritated by being rubbed SKIN with a sharp object, such as a thumbnail, the infant (*UNDER APPEARANCE OF NEWBORN ) raises the other leg and extends it, as if trying to push away the hand irritating the first leg. COLOR (*UNDER SKIN) TRUNK INCURVATION REFLEX RUDDY COMPLEXION  When newborns lie in a prone position and are touched along the paravertebral area by a probing  Increased concentration of red blood cells in blood finger, they flex their trunk and swing their pelvis vessels and a decrease in the amount of toward the touch subcutaneous fat, which makes the blood vessels more visible. This ruddiness fades slightly over the LANDAU REFLEX first month.  A newborn who is held in a prone position with a PALE AND CYANOTIC hand underneath, supporting the trunk, should demonstrate some muscle tone. Babies may not be  Infants with poor central nervous system control. able tolift their head or arch their back in this position (as they will at 3 months of age), but GRAY COLOR neither should they sag into an inverted “U” position. The latter response indicates extremely poor muscle tone, the cause of which should be  Generally indicates infection. investigated. CYANOSIS VISION  Generalized mottling of the skin is common. A  Newborns see as soon as they are born and newborn’s lips, hands, and feet are likely to appear possibly have been “seeing” light and dark in utero blue from immature peripheral circulation. for the last few months of pregnancy, as the uterus and the abdominal wall were stretched thin. ACROCYANOSIS Newborns demonstrate sight at birth by blinking at a strong light (blink reflex) or by following a bright light  (Blueness of hands and feet) is so prominent in or toy a short distance with their eyes. some newborns that it appears as if some stricture were cutting off circulation, with usual skin color on one side and blue on the other. Acrocyanosis is a Historillo, Santia Jumel P. 4 of 9 THE NEWBORN NCMA217 normal phenomenon in the first 24 to 48 hours after a) excessive blood loss when the cord was cut, birth b) inadequate flow of blood from the cord into the infant at birth, CENTRAL CYANOSIS c) fetal–maternal transfusion, d) low iron stores caused by poor maternal nutrition  indicates decreased oxygenation. It may be the during pregnancy, or result of a temporary respiratory obstruction or an e) blood incompatibility in which a large number of red underlying disease state. blood cells were hemolyzed in utero. It also may be the result of internal bleeding. A baby who appears pale should be watched closely for signs of blood in HYPERBILIRUBINEMIA stool or vomitus.  Hyperbilirubinemia leads to jaundice, or yellowing of HARLEQUIN SIGN the skin (Beachy, 2007). This occurs on the second or third day of life in about 50% of all newborns, as  Occasionally, because of immature circulation, a a result of a breakdown of fetal red blood cells newborn who has been lying on his or her side (physiologic jaundice). The infant’s skin and the appears red on the dependent side of the body and sclera of the eyes appear noticeably yellow. This pale on the upper side, as if a line had been drawn happens because the high red blood cell count built down the center of the body. This is a transient up in utero is destroyed, and heme and globin are phenomenon; although startling, it is of no clinical significance. The odd coloring fades immediately if released. the infant’s position is changed or the baby kicks or  After the level of this indirect bilirubin has risen to cries vigorously. more than 7 mg/100 mL, however, bilirubin permeates the tissue outside the circulatory system BIRTHMARKS and causes the infant to appear jaundiced. (UNDER SKIN)  Observe infants who are prone to extensive It is important to be able to differentiate the various types of bruising (large, breech, or immature babies) hemangiomas that occur, so that you neither give false carefully for jaundice, because bruising leads to reassurance to parents nor worry them unnecessarily about hemorrhage of blood into the subcutaneous tissue these lesions. or skin. A cephalhematoma is a collection of blood under the periosteum of the skull bone. As the bruising in these locations heals and the red blood HEMANGIOMA cells are hemolyzed, additional indirect bilirubin is released and can be another cause of jaundice  The hemangiomas are vascular tumors of the skin.  Above-normal indirect bilirubin levels are potentially Three types occur. dangerous because, if enough indirect bilirubin a) Nevus Flammeus: is a macular purple or (about 20 mg/100 mL) leaves the bloodstream, it dark-red lesion (sometimes called a portwine can interfere with the chemical synthesis of brain stain because of its deep color) that is cells, resulting in permanent cell damage, a present at birth. These lesions typically condition termed kernicterus. If this occurs, appear on the face, although they are often permanent neurologic damage, including cognitive found on the thighs as well. Those above the challenge, may result.  There is no set level at which indirect serum bridge of the nose tend to fade; the others are bilirubin requires treatment, because other factors, less likely to fade. Because they are level with such as age, maturity, and breastfeeding status, the skin surface (macular), they can be affect this determination. If the level rises to more covered by a cosmetic preparation later in life than 10 to 12 mg/100 mL, treatment is usually or removed by laser therapy, although lesions considered. Phototherapy (exposure of the infant may reappear after treatment. Nevus to light to initiate maturation of liver enzymes) is a flammeus lesions also occur as lighter, pink common therapy. If this is necessary, the incubator patches at the nape of the neck, known as and light source can be moved to the mother’s room so that the mother is not separated from her stork’s beak marks or telangiectasia. baby. Some infants need continued therapy after These do not fade, but they are covered by discharge and receive phototherapy at home. the hairline and therefore are of no  Compared with formula-fed babies, a small consequence. They occur more often in proportion of breastfed babies may have more females than in males. difficulty converting indirect bilirubin to direct b) Strawberry hemangioma: refers to elevated bilirubin, because breast milk contains pregnanediol areas formed by immature capillaries and (a metabolite of progesterone), which depresses endothelial cells. Most are present at birth in the action of glucuronyl transferase. However, breastfeeding alone rarely causes enough jaundice the term neonate, although they may appear to warrant therapy up to 2 weeks after birth. Typically, they are not present in the preterm infant because of PALLOR the immaturity of the epidermis. Formation is associated with the high estrogen levels of  Pallor in newborns is usually the result of anemia. pregnancy. They may continue to enlarge This may be caused by: from their original size up to 1 year of age. Historillo, Santia Jumel P. 5 of 9 THE NEWBORN NCMA217 After the first year, they tend to be absorbed between 37 to 39 weeks of gestation has more and shrink in size. By the time the child is 7 lanugo than a newborn of 40 weeks’ gestational years old, 50% to 75% of these lesions have age. Postmature infants (more than 42 weeks of disappeared. A child may be 10 years old gestation) rarely have lanugo. Lanugo is rubbed away by the friction of bedding and clothes against before the absorption is complete. Application the newborn’s skin. By 2 weeks of age, it has of hydrocortisone ointment may speed the disappeared. disappearance of these lesions by interfering with the binding of estrogen to its receptor DESQUAMATION sites. (UNDER SKIN) c) Cavernous hemangiomas - are dilated vascular spaces. They are usually raised and  Within 24 hours after birth, the skin of most newborns has become extremely dry. The dryness resemble a strawberry hemangioma in is particularly evident on the palms of the hands appearance. However, they do not disappear and soles of the feet. This results in areas of with time as do strawberry hemangiomas. peeling similar to those caused by sunburn. This is Such lesions can be removed surgically. normal, however, and needs no treatment. Parents Steroids, interferon-alfa-2a, or vincristine can may apply hand lotion to prevent excessive dryness be used to reduce these lesions in size, if they wish. although their use must be weighed in light of side effects. Children who have a skin lesion MILIA (UNDER SKIN) may have additional ones on internal organs. Blows to the abdomen, such as those from  All newborn sebaceous glands are immature. At childhood games, can cause bleeding from an least one pinpoint white papule (a plugged or internal hemangioma. For this reason, unopened sebaceous gland) can be found on the children with cavernous hemangiomas usually cheek or across the bridge of the nose of almost have their hematocrit levels assessed at every newborn. Such lesions, termed milia, disappear by 2 to 4 weeks of age, as the health maintenance visits, to evaluate for sebaceous glands mature and drain. Teach parents possible internal blood loss. to avoid scratching or squeezing the papules, to prevent secondary infections. MONGOLIAN SPOTS ERYTHEMA TOXICUM (UNDER SKIN)  Mongolian spots are collections of pigment cells (melanocytes) that appear as slate-gray patches  In most normal mature infants, a newborn rash across the sacrum or buttocks and possibly on the called erythema toxicum can be observed. This arms and legs. They tend to occur in children of usually appears in the first to fourth day of life but Asian, southern European, or African ethnicity may appear up to 2 weeks of age. It begins with a (Thilo& Rosenberg, 2008). They disappear by papule, increases in severity to become erythema school age without treatment. Be sure to inform by the second day, and then disappears by the third parents that these are not bruises; otherwise, they day. It is sometimes called a flea-bite rash because may worry their baby sustained a birth injury. the lesions are so minuscule. One of the chief characteristics of the rash is its lack of pattern. It VERNIX CASEOSA occurs sporadically and unpredictably and may last (UNDER SKIN) hours rather than days. It is caused by a newborn’s eosinophils reacting to the environment as the  Is a white, cream cheese–like substance that immune system matures. It requires no treatment. serves as a skin lubricant in utero. Usually, it is noticeable on a term newborn’s skin, at least in the SKIN TURGOR skin folds, at birth. Document the color of vernix, (UNDER SKIN) because it takes on the color of the amniotic fluid. For example, a yellow vernix implies that the  Newborn skin should feel resilient if the underlying amniotic fluid was yellow from bilirubin; green vernix tissue is well hydrated. If a fold of the skin is indicates that meconium was present in the grasped between the thumb and fingers, it should amniotic fluid. Until the first bath, when vernix is feel elastic. When it is released, it should fall back washed away, handle newborns with gloves to to form a smooth surface. If severe dehydration is protect yourself from exposure to this body fluid. present, the skin will not smooth out again but will Never use harsh rubbing to wash away vernix. A remain in an elevated ridge. Poor turgor is seen in newborn’s skin is tender, and breaks in the skin newborns who suffered malnutrition in utero, who caused by too vigorous attempts at removal may have difficulty sucking at birth, or who have certain open portals of entry for bacteria. metabolic disorders such as adrenocortical insufficiency. LANUGO (UNDER SKIN) HEAD (*UNDER APPEARANCE OF NEWBORN)  Is the fine, downy hair that covers a newborn’s shoulders, back, and upper arms. It may be found A newborn’s head appears disproportionately large because also on the forehead and ears. A baby born it is about one fourth of the total body length; in an adult, a Historillo, Santia Jumel P. 6 of 9 THE NEWBORN NCMA217 head is one eighth of total height. The forehead of a newborn gradually absorbed and disappears at about the is large and prominent. The chin appears to be receding, and third day of life. It needs no treatment (Nicholson, it quivers easily if an infant is startled or cries. Well- 2007). nourished newborns have full-bodied hair; poorly nourished and preterm infants have thin, lifeless hair. If internal fetal CEPHALHEMATOMA monitoring was used during labor, a newborn may exhibit a pinpoint ulcer at the point where the monitor was attached.  A collection of blood between the periosteum of a skull bone and the bone itself, is caused by rupture FONTANELLES of a periosteal capillary because of the pressure of birth. Swelling usually appears 24 hours after  The fontanelles are the spaces or openings where birth. Although the blood loss is negligible, the the skull bones join. The anterior fontanelle is swelling is usually severe and is well outlined as an located at the junction of the two parietal bones and egg shape. It may be discolored (black and blue) the two fused frontal bones. It is diamond shaped because of the presence of coagulated blood. and measures 2 to 3 cm (0.8 to 1.2 in) in width and  A cephalhematoma is confined to an individual 3 to 4 cm (1.2 to 1.6 in) in length. The posterior bone, so the associated swelling stops at the fontanelle is located at the junction of the parietal bone’s suture line. It often takes weeks for a bones and the occipital bone. It is triangular and cephalhematoma to be absorbed. It might be measures about 1 cm (0.4 in) in length. supposed that the blood could be aspirated to  The anterior fontanelle can be felt as a soft spot. It relieve the condition. However, such a procedure should not appear indented (a sign of dehydration) would introduce the risk of infection and is or bulging (a sign of increased intracranial unnecessary, because the condition will subside by pressure) when the infant is held upright. The itself. As the blood captured in the space is broken fontanelle may bulge if the newborn strains to pass down, a great amount of indirect bilirubin may be a stool or cries vigorously or is lying supine. With released, leading to jaundice. vigorous crying, a pulse may additionally be seen in CRANIOTABES the fontanelle. The anterior fontanelle normally closes at 12 to 18 months of age. In some newborns, the posterior fontanelle is so small that it  Is a localized softening of the cranial bones that is cannot be palpated readily. The posterior fontanelle probably caused by pressure of the fetal skull closes by the end of the second month. against the mother’s pelvic bone in utero. It is more common in firstborn infants than in infants born SUTURES later, because of the lower position of the fetal head in the pelvis during the last 2 weeks of pregnancy in  The skull sutures, the separating lines of the skull, primiparous women. With craniotabes, the skull is may override at birth because of the extreme so soft that the pressure of an examining finger can pressure exerted on the head during passage indent it. The bone returns to its normal contour through the birth canal. If the sagittal suture after the pressure is removed. The condition between the parietal bones overrides, the corrects itself without treatment after a few months, fontanelles are less perceptible than usual. The as the infant takes in calcium in milk. overriding subsides in 24 to 48 hours.  Suture lines should never appear widely separated EYES (*UNDER APPEARANCE OF NEWBORN) in newborns. Wide separation suggests increased intracranial pressure because of abnormal brain Newborns usually cry tearlessly, because their lacrimal ducts formation, abnormal accumulation of cerebrospinal do not fully mature until about 3 months of age. Almost fluid in the cranium (hydrocephalus), or an without exception, the irises of the eyes of newborns are accumulation of blood from a birth injury such as gray or blue; the sclera may be blue because of its thinness. subdural hemorrhage. Fused suture lines also are Infant eyes assume their permanent color between 3 and 12 abnormal; they require radiographic confirmation months of age. To inspect the eyes, lay the newborn in a and further evaluation, because they will prevent supine position and lift the head. This maneuver causes the the head from expanding with brain growth. baby to open the eyes. A newborn’s eyes should appear MOLDING clear, without redness or purulent discharge.  The part of the infant’s head that engaged the EARS (*UNDER APPEARANCE OF NEWBORN) cervix (usually the vertex) molds to fit the cervix contours during labor. After birth, this area appears A newborn’s external ear is not as completely formed as it prominent and asymmetric. Molding may be so will be eventually, so the pinna tends to bend easily. In the extreme in the baby of a primiparous woman that term newborn, however, the pinna should be strong enough the baby’s head appears as a dunce cap. The head to recoil after bending. The level of the top part of the will restore to its normal shape within a few days external ear should be on a line drawn from the inner after birth. canthus to the outer canthus of the eye and back across the CAPUT SUCCEDANEUM side of the head. Ears that are set lower than this are found in infants with certain chromosomal abnormalities, particularly trisomy 18 and 13, syndromes in which low-set  Caput succedaneum is edema of the scalp at the ears and other physical defects are coupled with varying presenting part of the head. It may involve wide degrees of cognitive challenge. areas of the head, or it may resemble a large egg. The edema, which crosses the suture lines, is Historillo, Santia Jumel P. 7 of 9 THE NEWBORN NCMA217 good practice is to test a newborn’s hearing by ringing a bell anteroposterior diameter as it is across. Not until a child is 2 held about 6 inches from each ear. A hearing infant who is years of age does the chest measurement exceed that of the crying will stop momentarily at the sound. If quiet, a newborn head. The clavicles should be straight. A crepitus or actual who can hear will blink the eyes, appear to attend to the separation on one or the other clavicle may indicate that a sound, and possibly startle. Although this method of testing fracture occurred during birth and calcium is now being is not highly accurate, a negative response (lack of deposited at that point. response) is unusual. Overall, a newborn’s chest should appear symmetric side to NOSE side. Respirations are normally rapid (30 to 60 breaths per (*UNDER APPEARANCE OF NEWBORN) minute) but not distressed. A supernumerary nipple (usually found below and in line with the normal nipples) may be A newborn’s nose tends to appear large for the face. As the present. If so, it may be removed later for cosmetic purposes infant grows, the rest of the face grows more than the nose although this is not necessary. does, and this discrepancy disappears. Test for choanal atresia (blockage at the rear of the nose) by closing the In both female and male infants, the breasts may be newborn’s mouth and compressing one naris at a time with engorged. Occasionally, the breasts of newborn babies your fingers. Note any discomfort or distress while breathing secrete a thin, watery fluid popularly termed witch’s milk. this way. Nasal flaring upon inspiration is another indication Engorgement develops in utero as a result of the influence of of respiratory distress and should be further evaluated. Also the mother’s hormones. As soon as the hormones are record any evidence of milia on the nose. cleared from the infant’s system (about 1 week), the engorgement and any fluid that is present subside. MOUTH (*UNDER APPEARANCE OF NEWBORN) Retraction (drawing in of the chest wall with inspiration) should not be present. An infant with retractions is using A newborn’s mouth should open evenly when he or she such strong force to pull air into the respiratory tract that he cries. If one side of the mouth moves more than the other, or she is pulling in the anterior chest muscle. An abnormal cranial nerve injury is suggested. A newborn’s tongue sound, such as grunting, suggests respiratory distress appears large and prominent in the mouth. Because the syndrome; a high, crowing sound on inspiration suggests tongue is short, the frenulum membrane is attached close to stridor or immature tracheal development. the tip of the tongue, creating the impression that the infant is “tongue tied.” ABDOMEN (*UNDER APPEARANCE OF NEWBORN) Inspect the palate of a newborn to be sure it is intact. Occasionally, one or two small, round, glistening, well The contour of a newborn abdomen looks slightly circumscribed cysts (Epstein’s pearls) are present on the protuberant. A scaphoid or sunken appearance may indicate palate, a result of extra calcium that was deposited in utero. missing abdominal contents or a diaphragmatic hernia Be sure to inform parents that these pearl-like cysts are (bowel positioned in the chest instead of the abdomen). insignificant, require no treatment, and will disappear Bowel sounds should be present within 1 hour after birth. spontaneously within 1 week. Otherwise, a parent may The edge of the liver is usually palpable 1 to 2 cm below the mistake them for thrush, a Candida infection, which usually right costal margin. The edge of the spleen may be palpable appears on the tongue and sides of the cheeks as white or 1 to 2 cm below the left costal margin. Tenderness is difficult gray patches and needs therapy with an antifungal drug to determine in a newborn. If it is extreme, however, (Subramanian et al., 2008). palpation will cause the infant to cry, thrash about, or tense the abdominal muscles to protect the abdomen. NECK (*UNDER APPEARANCE OF NEWBORN) For the first hour after birth, the stump of the umbilical cord appears as a white, gelatinous structure marked with the The neck of a newborn is short and often chubby, with blue and red streaks of the umbilical vein and arteries. When creased skin folds. The head should rotate freely on it. If the cord is first cut, the vessels are counted to be certain that there is rigidity of the neck, congenital torticollis, caused by one vein and two arteries are present. injury to the sternocleidomastoid muscle during birth, might be present. In newborns whose membranes were ruptured Inspect the cord clamp to be certain it is secure. After the more than 24 hours before birth, nuchal rigidity suggests first hour of life, the cord begins to dry and shrink, and it meningitis. turns brown like the dead end of a vine. By the second or third day, it has turned black. It breaks free by day 6 to 10, The neck of a newborn is not strong enough to support the leaving a granulating area a few centimeters wide that heals total weight of the head but in a sitting position, a newborn during the following week. should make a momentary effort at head control. When lying prone, newborns can raise the head slightly, usually enough The base of the cord should appear dry. A moist or odorous to lift the nose out of mucus or spit-up formula. If they are cord suggests infection. If present, infection should receive pulled into a sitting position from a supine position, the head immediate treatment or it may enter a newborn’s will lag behind considerably. bloodstream and cause septicemia. CHEST To finish the abdominal assessment, elicit an abdominal (*UNDER APPEARANCE OF NEWBORN) reflex. Stroking each quadrant of the abdomen will cause the umbilicus to move or “wink” in that direction. This superficial The chest in some newborns looks small because the head abdominal reflex is a test of spinal nerves T8–T10. The is large in proportion. It is actually approximately 2 inches reflex may not be demonstrable in newborns until the 10th smaller in circumference than and as wide in the day of life. Historillo, Santia Jumel P. 8 of 9 THE NEWBORN NCMA217 ANOGENITAL A further test for subluxation can be elicited by holding the (*UNDER APPEARANCE OF NEWBORN) infant’s leg with the fingers on the greater and lesser trochanter and then abducting the hip; if subluxation is Area Inspect the anus of a newborn to be certain it is present, a “clunk” of the femur head striking the shallow present, patent, and not covered by a membrane acetabulum can be heard (Ortolani’s sign). If the hip can be (imperforate anus). Test for anal patency by gently inserting felt to actually slip in the socket, this is Barlow’s sign. the tip of your gloved and lubricated little finger. Also note the time after birth at which the infant first passes meconium. Subluxated hip may be bilateral but is usually unilateral. It is If a newborn does not do so in the first 24 hours, suspect important that hip subluxation be discovered as early as imperforate anus or meconium ileus. possible, because correction is most successful if it is initiated early. BACK (*UNDER APPEARANCE OF NEWBORN) FEMALE GENITALIA The spine of a newborn typically appears flat in the lumbar  The vulva in female newborns may be swollen and sacral areas. The curves seen in an adult appear only because of the effect of maternal hormones. Some after a child is able to sit and walk. Inspect the base of a female newborns have a mucus vaginal secretion, newborn’s spine carefully to be sure there is no pinpoint which is sometimes blood-tinged opening, dimpling, or sinus tract in the skin, which (pseudomenstruation). Again, this is caused by the would.suggest a dermal sinus or spinal bifida occulta. True action of maternal hormones. The discharge neural tube defects in newborns are greatly decreased in disappears as soon as the infant’s system has incidence because of the recognition that lack of folic acid cleared the hormones. The discharge should not be during pregnancy leads to these (De Wals et al., 2007). mistaken for an infection or taken as an indication A newborn normally assumes the position maintained in that trauma has occurred. utero, with the back rounded and the arms and legs flexed on the abdomen and chest. A child who was born in a frank MALE GENITALIA breech position tends to straighten the legs at the knee and bring their feet up next to the face.  The scrotum in most male newborns is edematous and has rugae (folds in the skin). It may be deeply EXTREMITIES pigmented in African American or dark-skinned (*UNDER APPEARANCE OF NEWBORN) newborns. Make a practice of pressing your The arms and legs of a newborn appear short. The hands nondominant hand against the inguinal ring before are plump and clenched into fists. Newborn fingernails are palpating for testes, so they do not slip upward and soft and smooth, and usually long enough to extend over the out of the scrotal sac as you palpate. fingertips. Test the upper extremities for muscle tone by  Both testes should be present in the scrotum. If one unflexing the arms for approximately 5 seconds. If tone is or both testicles are not present (cryptorchidism), good, an arm should return immediately to its flexed position referral is needed to establish the extent of the after being released. Hold the arms down by the sides and problem. This condition could be caused by note their length. The fingertips should reach the proximal agenesis (absence of an organ), ectopic testes (the thigh. Unusually short arms may signify achondroplastic testes cannot enter the scrotum because the dwarfism. Observe for unusual curvature of the little finger, opening to the scrotal sac is closed), or and inspect the palm for a simian crease (a single palmar undescended testes (the vas deferens or artery is crease, in contrast to the three creases normally seen in a too short to allow the testes to descend). palm). Although curved fingers and simian creases can  Elicit a cremasteric reflex by stroking the internal occur normally, they are commonly associated with Down side of the thigh. As the skin is stroked, the testis on syndrome. that side moves perceptibly upward. This is a test for the integrity of spinal nerves T8–T10. The Assess for webbing (syndactyly), extra toes or fingers response may be absent in newborns who are (polydactyly), or unusual spacing of toes, particularly younger than 10 days. The penis of newborns between the big toes and the others (this finding is present in appears small, approximately 2 cm long. If it is less certain chromosomal disorders, although it is also a normal than this, the newborn should be referred for finding in some families). Test to see whether the toenails fill evaluation by an endocrinologist. Inspect the tip of immediately after blanching from pressure. Normally, the penis to see that the urethral opening is at the newborn legs are bowed as well as short. The sole of the tip of the glans, not on the dorsal surface foot appears flat because of an extra pad of fat in the (epispadias) or on the ventral surface longitudinal arch. The foot of a term newborn has many (hypospadias). crisscrossed lines on the sole, covering approximately twothirds of the foot. If these creases cover less than two- thirds of the foot or are absent, suspect immaturity.  Reference/s: Textbook Adele Pilliteri, JoAnne Silbert-Flagg. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. (8 th Ed.). With a newborn in a supine position, both hips can be flexed Wolters Kluwer. Audrey Berman, Shirlee J. Snyder, GeralynFrandsen. (n.d.). Fundamentals of Nursing by Kozier and Erbs and abducted to such an extent (180 degrees) that the knees (10th ed.). touch or nearly touch the surface of the bed. If the hip joint Pearson. Maternal and Child Health. (n.d.). https://apha.org/topics-and-issues/maternal-and-child-health seems to lock short of this distance (160 to 170 degrees), hip subluxation (a shallow and poorly formed acetabulum) is Maternal, newborn and adolescent health. (n.d.). https://www.who.int/maternal_child_adolescent/en/ suggested. Rosalinda ParadoSalustiano. (2009). Dr. RPS Maternal & Newborn Care: A Comprehensive Review Guide and Source Book for Teaching and Learning. C & E Publishing, Inc. The American Journal of Maternal and Child Nursing. (n.d.). https://journals.lww.com/mcnjournal/pages/default.aspx Historillo, Santia Jumel P. 9 of 9