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RNC Assessment of newborn
Terms in this set (26)
Abnormal assessment of skin
4. Cool to touch.
5. Poor perfusion.
Abnormal assessment of respiratory
1. Poor color.
3. Decreased air entry.
4. Increased work of breathing: grunting, flaring, and retracting.
6. Unequal breath sounds.
7. Oxygen requirement.
Abnormal assessment of cardiovascular
1. Abnormal heart sounds such as murmur.
2. Weak, absent, or unequal pulses.
Abnormal assessment of CNS
1. Hypertonic or hypotonic.
2. Jitteriness, tremors.
4. Bulging fontanelle (record baseline head circumference).
6. Irritability, high-pitched cry.
1. Congenital anomalies (e.g., abdominal wall defects, imperforate anus).
2. Severe birth trauma.
3. Absent or decreased limb movement.
Abnormal GI assessment
1. Abdominal distention (measure baseline abdominal girth).
2. Increased gastric contents on aspiration.
3. Inability to pass an orogastric tube.
4. Excessive mucus.
5. Emesis soon after birth or after first feeding.
A. Pulse oximetry (peripheral monitoring of oxygen saturation). 1. Oxygen saturation (Sao2) of blood is that percentage of the total hemoglobin concentration that is chemically combined with oxygen.
2. A baseline Pao2 value should be obtained to confirm the infant's oxygen level.
3. For hyperoxic study, administer 100% oxygen to differentiate between pulmonary and cardiac disease. (In infants with pulmonary disease, saturation will improve, whereas in infants with cyanotic heart disease, little or no change will occur. Use caution to avoid exposing the ductus arteriosus to high oxygen levels in ductal-dependent cardiac lesions.)
B. Arterial blood gas determinations. If oxygen requirement persists, pulse oximetry saturations in room air are decreased and cyanosis is present.
C. Chest x-ray examination. Anteroposterior and lateral views are needed if respiratory distress is present or cardiac disease is suspected.
D. Transillumination. Use a high-intensity light placed over the side of the chest in question if pneumothorax or pneumomediastinum is suspected.
E. Whole-blood glucose screening test or serum glucose determination if indicated by history or assessment results (see Routine Care Considerations in the Transition Nursery, item D: Glucose Needs/First Feeding, on p. 80).
F. Hematocrit determination.
1. History of blood loss.
2. Plethoric or pale infant.
3. Twins (to rule out twin-to-twin transfusion).
4. Heel-stick (capillary) samples tend to have higher results of approximately 10%.
5. Hematocrit variations. Highest hematocrit is at 2 to 4 hours of age and then progressively falls as a result of the beginning of red blood cell breakdown and the cessation of erythropoiesis in response to a comparatively oxygen-enriched environment.
G. Complete blood cell count with differential examination of the white blood cells.
1. As part of a sepsis diagnostic evaluation.
2. To screen for normal and abnormal hematologic indices.
H. Blood culture as part of a diagnostic evaluation for sepsis.
I. Urine sample collection.
2. Screening test for drugs of abuse.
J. Lumbar puncture: Performed at the discretion of the physician as part of a diagnostic evaluation for sepsis.
K. Ultrasonography, computed tomography, and magnetic resonance imaging.
1. Cranial evaluation for abnormal central nervous system (CNS) findings.
2. Abdominal examination if history of two-vessel cord to rule out renal anomalies.
L. Echocardiography and electrocardiography: As part of a diagnostic study for a congenital cardiac defect.
M. Passage of orogastric tube.
1. To check patency of esophagus in infants with excessive pooling of mucus in the oropharynx.
2. To decompress a distended abdomen.
3. To measure and assess gastric contents (>25 ml and/or significant bile in the stomach indicates obstruction).
Within 12 to 18 hours of life: evaluation of size, growth, and GA; transition to extrauterine life; and congenital anomalies.
b. Discharge examination: focus on problem(s) during hospitalization, problems with feeding and weight gain, and ability of parent(s) to meet infant's needs.
Assessment of color
Color (Sniderman and Taeusch, 2005). a. Most reliable indicator of color: mucous membranes. Other areas include conjunctiva, nail beds, lips, buccal mucosa, earlobes, and soles of feet.
b. Lighting and color of blankets can affect perception of color.
c. Central cyanosis; always abnormal (1) Recognition influenced by hematocrit, temperature, and environmental factors.
(2) Central cyanosis: superficial capillaries exceed 5 g/dl unsaturated hemoglobin (Roberton, 2000).
(3) Variety of etiologies: cardiac, pulmonary, infection, metabolic, neurologic, and hematologic.
d. Acrocyanosis. (1) Suggests instability of peripheral circulation.
(2) Cyanosis limited to hands, feet, and circumoral area (lips).
(3) May be a result of cold, stress, shock, and polycythemia.
(4) Normal finding for 24 to 48 hours after birth.
e. Pallor: pale, white appearance. (1) Reflects poor perfusion and circulatory failure or acidosis.
(2) With bradycardia indicates anoxia or vasoconstriction found in shock, sepsis, or severe respiratory distress.
(3) With tachycardia can indicate anemia.
f. Plethora: ruddy or red appearance. (1) May indicate polycythemia.
g. Jaundice: yellow pigmentation in skin or conjunctiva due to deposition of bilirubin. (1) Abnormal in the first 24 hours of life. Needs immediate investigation.
(2) Cephalocaudal progression.
h. Mottling: checkerboard red and white pattern. (1) May be normal in neonatal period, especially in preterm infants. Reflects vasomotor instability and unequal capillary blood to cutaneous tissue.
(2) May be seen in cold stress, hypovolemia, and sepsis.
(3) Cutis marmorata: exaggerated marbling greatest on extremities but also present on trunk (Fletcher, 1998).
i. Harlequin sign: distinct midline demarcation. (1) Pale on one side and red on the opposite side.
(2) Owing to immature autoregulation of blood flow.
Assessment of Respiratory system
a. Rate. (1) Normal 40 to 60 respirations per minute.
(2) Rate can vary with activity of infant.
b. Quality: absence of "work of breathing." (1) Retractions: occur more often in premature as a result of highly compliant chest wall (Bates and Balistreri, 2002).
(2) Nasal flaring: diameter of nares increased as mechanism to decrease airway resistance.
(3) Expiratory grunting: increase in intrathoracic pressure to prevent volume loss during expiration as a result of alveolar collapse.
4. Wheezing: due to increased airway resistance. High-pitched rhonchi heard more loudly on expiration.
5. Stridor: partially obstructed airway.
Assessment of tone
Based on GA expectations.
b. Initial position reflects intrauterine position and may reflect limitation of movement or increased pressure on head, trunk, or extremities.
c. Degree of flexion and amount of resistance demonstrated with examiner's extension of extremities.
d. Decreased flexion (hypotonia) or increased flexion (hypertonia) should be evaluated further.
Assessment of Congenital anomalies
a. Determine if malformation (abnormal shape or structure) or deformation (fully formed but influenced by in utero environment). b. Describe anatomic structures fully: size, number, shape, position, color, texture, continuity, and alignment (Sniderman and Taeusch, 2005).
Assessment of Skin
1. General considerations.
a. Findings differ with GA, especially with extremely low birth weight.
b. Indicators of underlying illness: petechiae, pigmentation, rashes, and pustules.
c. Congenital lesions may not be apparent at birth; influenced by maternal hormones.
d. Differentiate between findings at birth vs. injury after birth (medical interventions).
e. Use basic descriptors: color, quantity, size, shape, pattern of distribution, and texture (Lund and Kuller, 2007).
2. Skin is soft, smooth, and opaque and should be warm to the touch; cold, clammy skin may indicate shock.
3. Inspect lesions, rashes, bruises, and birthmarks. Differentiate between benign findings and those suspicious of infection or hematologic or neurologic disturbance.
4. Palpate for texture (raised, flat) unless lesion is open.
5. Vernix caseosa. a. White or yellow material on the skin; discolored with postmaturity, hemolytic disease, and meconium staining.
b. Sebaceous gland secretions and exfoliated skin cells.
c. Presents during third trimester and decreases with increasing GA.
6. Lanugo: fine soft hair covering face, trunk. a. Amount and distribution are GA dependent.
b. Covers entire body in preterm, disappears at 32 to 37 weeks from face and lower back.
c. At term, present on upper back and limbs.
7. Erythema toxicum (newborn rash). a. Erythematous macules, each containing a central papule (yellow or white).
b. Papules contain eosinophils in a fluid that is sterile.
c. Persist for several days and then resolve spontaneously.
d. Most often located on trunk, arms, and perineal areas.
e. Never located on soles of feet or palms of hands.
8. Pustular melanosis. a. Benign, transient, nonerythematous pustules and vesicles.
b. Single or clusters, rupture leaves scaly white lesion.
9. Ecchymosis: nonblanching blue or black area. a. Extravasation of blood into tissue.
b. Related to trauma of blood vessels.
a. Tiny red or purple nonblanching pinpoint macules.
b. Benign when found on presenting part; result from areas of compression during delivery.
c. More diffuse distribution suggests general thrombocytopenia.
d. Require further evaluation when progressive (Lund and Kuller, 2007).
11. Vascular nevi. a. Common cutaneous malformation(s) that can occur anywhere on body.
b. May present at birth or may develop in early infancy.
c. Types. (1) Nevus simplex or capillary hemangiomas (stork bite). (a) Macular patches with diffuse borders.
(b) Found on forehead, nape of neck, glabella, and eyelids.
(c) Blanch when pressure is applied.
(d) Resolve spontaneously.
(2) Nevus flammeus (port wine stain). (a) Flat, sharply defined lesion.
(b) Most common on back of neck
(c) If present over the face following branches of trigeminal nerve (forehead and upper eyelid), may be associated with Sturge-Weber syndrome.
(d) Will not blanch with pressure.
(e) May fade with time but will not resolve.
12. Café au lait spots. a. Light tan or brown macules with well-defined borders.
b. Deeper pigmentation than surrounding skin.
c. Six or more may be pathologic.
13. Strawberry hemangioma(s). a. Red, raised, circumscribed, and compressible.
b. Can occur anywhere on the body.
c. Proliferate: increase in size and number.
d. Most involute spontaneously.
e. No treatment is required unless they affect vital function.
f. Occur with increasing frequency with decreased GA.
14. Epidermolysis bullosa. a. Blistering internally and externally.
b. May be either autosomal dominant or recessive.
15. Staphylococcal scalded skin syndrome. a. Skin response to Staphylococcus aureus.
b. Scalded skin appearance.
16. Sucking blisters: skin erosion on thumbs, index fingers, wrist, or forearm from intrauterine sucking.
Assessment of Head
a. Up to 90% of the congenital malformations present at birth are apparent on the head and neck (Jones, 2005).
b. Review perinatal history, abnormal ultrasound findings, and mode of delivery.
c. Many variations are transient or racial, sexual, or familial traits.
2. Obtain head circumference (HC) measurements. a. Measurement reflects brain growth.
b. Predictable measurement: follows norms for GA and weight.
c. Usually HC falls on same percentile curve as length. Determine etiology of abnormal growth if length and HC differ by greater than one quartile (Sansoucie and Cavaliere, 2007).
d. HC should be 2 cm larger than the chest circumference. Normal = 32 to 38 cm for full-term AGAs. (1) Microcephalic: poor brain growth, atrophy, or premature cranial synostosis.
(2) Macrocephalic: familial (follows persistently higher but consistent growth curve) and pathologic (hydrocephalus: increase in cerebrospinal fluid results in increasing HC).
3. Observe shape and symmetry; may reflect effect of birth process or in utero position or significant anatomic defect. a. Molding. (1) Occurs with vaginal delivery from a vertex position; adaptive mechanism to facilitate passage through birth canal.
(2) Elongation of head with prominence of occiput and overriding sagittal suture line.
(3) Resolution in first week of life.
(4) Not uncommon for overriding sutures to persist longer than 1 week in the extremely low birth weight infant.
b. Rounded head occurs with delivery by cesarean section without labor; flat head with increased occipital-frontal diameter occurs with breech delivery.
c. Abnormal prominence, depressions, or flattening.
d. Abnormal shape of skull. (1) Plagiocephaly: asymmetric appearance of head, flattened on one side.
(2) Craniosynostosis: premature closing of one or more of cranial sutures.
(3) Anencephaly: failed closure of neural tube without skull formation.
4. Palpate sutures and fontanelles (Fig. 7-7). a. Sutures: check for mobility of sutures by placing thumb on opposite sides of suture and alternately pushing (gently).
(1) Well approximated.
(2) Overriding. (a) Molding.
(b) Fused suture: premature synostosis.
(3) Wide sutures. (a) May be wide in the absence of increased intracranial pressure.
(b) Widened lambdoid suture: indicates increased pressure.
(c) Sagittal and metopic sutures normally wider in black infants (Fletcher, 1998).
(4) Craniotabes: soft demineralized area typically found in parietal and occipital regions along the lambdoidal suture line. (a) Under gentle pressure, the area will collapse and then recoil.
(b) Infant engaged in the vertex position for a prolonged period.
(c) Pressure of skull against maternal pelvis results in delayed ossification or reabsorption of bone.
b. Anterior fontanelle.
(1) Location: junction of sagittal and coronal sutures.
(2) Shape: diamond.
(3) Size: measures 4 to 6 cm at the largest diameter (bone to bone).
(4) Normally closes at 18 months.
c. Posterior fontanelle.
(1) Location: junction of lambdoidal and sagittal sutures.
(2) Shape: triangular.
(3) Size: usually fingertip.
(4) Normally closes by 2 months of age.
d. Abnormal findings.
(1) Third fontanelle: between anterior and posterior fontanelles along the sagittal suture (may be associated with congenital anomalies).
(2) Size: large fontanelle, considerable racial variations; not pathognomonic for any condition (Fletcher, 1998).
(3) Closed fontanelles with immobile, rigid sutures suggest premature synostosis.
(4) Bruit over temporal, frontal, or occipital area associated with high-output cardiac failure and arteriovenous malformation.
(5) Abnormal tension. (a) Bulging, tense, full fontanelle: associated with increased intracranial pressure secondary to hydrocephalus, birth injury, bleeding, or infection.
(b) Depressed fontanelle: associated with dehydration.
5. Palpate soft tissue findings on scalp, face, and neck (Furdon and Clark, 2001). a. Caput succedaneum: common finding in infants born in the vertex position as a result of compression of local blood vessels.
(1) Maximal swelling present at birth.
(2) Edema extends across suture lines and has poorly defined borders.
(3) Edema can shift to dependent position.
(4) ± Ecchymosis, petechiae, or purpura.
(5) Disappears within 24 to 48 hours.
b. Cephalohematoma: subperiosteal hemorrhage due to traumatic delivery.
(1) Typically not present at birth, increases in size over the first day of life.
(2) Unilateral; fixed, firm, and palpable mass.
(3) Swelling does not cross suture lines.
(4) Often no ecchymosis.
(5) Poor tone, feeding, and decreased activity may be indication of underlying skull fracture.
(6) Resolution may not occur for several months, often leaving a calcified "knot."
c. Subgaleal hemorrhage: owing to forces that compress and drag the head through the pubic outlet.
(1) Is a clinical emergency.
(2) Ballotable scalp mass present at birth that is mobile, not fixed.
(3) Swelling crosses suture lines and fontanelles, poorly defined margins.
(4) Rapidly can increase in size and shape with significant acute blood loss, resulting in shock as the presenting symptom.
(5) Bleeding, seen as swelling, can expand to orbital ridges, around the ears and dissect along tissue planes into the neck.
(6) Least common of the birth injuries; however, has the greatest potential for complications.
6. Inspect the scalp. a. Intact skin.
b. Normal hair pattern (direction of growth) and distribution (Furdon and Clark, 2003). (1) Color concordant racially with parents; genetic disorders can present with hypopigmentation of scalp hair.
(2) Localized patches of hypopigmentation; e.g., white forelock: Waardenburg syndrome.
(3) Areas of diffuse or localized absence or abundance of hair.
(4) Hair texture: brittle, fragile, twisted, wooly, excessively kinky.
(5) Anterior and posterior hair margins.
c. Abnormal findings.
(1) Lacerations or abrasions as the result of instruments at delivery or scalp electrode.
(2) Vesicles: electrode site and behind the ears.
(3) Cutis aplasia: localized absence of skin associated with trisomy 13.
(4) Hair whorls: spiral hair growth pattern; multiple hair whorls or abnormal placement may represent abnormal brain growth or development.
(5) Anterior hairline well onto the forehead.
7. Note position infant holds head at rest.
a. Reflects fetal position.
b. Usual position: anterior neck flexion.
c. Observe for full range of motion.
Assessment of face
1. Observe for symmetry and location of eyes, nose, and mouth.
a. Divide the face into thirds for inspection: one third, forehead; one third, eyes and nose; and one third, mouth and chin.
b. At rest and with crying or sucking.
c. Asymmetry when infant crying: facial palsy.
2. Observe relationship and location of eyes, nose, and mouth.
a. Eyes. (1) Spacing and size.
(a) Space between inner and outer canthus of one eye approximates the width between the two inner canthi.
(b) Hypertelorism (widened distance between orbits); hypotelorism (decreased distance between orbits) associated with various syndromes.
(2) Number: anophthalmos (absent); cyclopia (one).
(3) Conjunctiva and sclera. (a) Subconjunctival hemorrhage: result from pressure on fetal head during delivery.
(b) Sclera color usually white.
(c) Blue sclera: extreme prematurity, osteogenesis imperfecta, other chromosomal associations.
(d) Yellow sclera: jaundiced.
(4) Cornea, iris, and pupils.
(a) Cornea relatively cloudy at birth:
(i) Term infant: cloudiness resolves within a few days.
(ii) Asymmetric or dense cloudiness: abnormal.
(iii) Infantile cataracts: rubella, cytomegalovirus, familial association, and chromosomal defect.
(b) Iris: dark blue until 3 to 6 months of age, then eye color may change.
(i) Brushfield's spots: speckled appearance; occurs in 75% of infants with trisomy 21; also normal (Fletcher, 1998).
(ii) Coloboma: cleft-shaped fissure (keyhole shape); can be sporadic or in association with trisomy 13 or choanal atresia, posterior coloboma, heart defect, choanal atresia, retardation, genital and ear abnormalities (CHARGE) sequence.
(i) PERRL (pupils equal, round, and react to light).
(ii) White color: abnormal.
(d) Red reflex: reflection of ophthalmoscope's light on the retina.
(e) Color range: red (light-skinned infant) to yellow (dark-skinned infant).
(i) White: congenital cataracts.
(ii) Absence: retinoblastoma, glaucoma, or hemorrhage.
(5) Symmetry of eye movements. (a) Eyelids.
(i) Should open to above midpoint of pupil when the eye is in a neutral position.
(ii) Edema: related to birth process or chemical irritation with eye prophylaxis.
(iii) Fused eyelids: extreme prematurity; generally not fused by 28 weeks of gestation; should not be used as an indicator of viability or nonviability.
(iv) Ptosis: abnormal drooping of one or both eyelids.
(b) Palpebral fissures.
(i) Slant is primarily racially determined.
(ii) Variations typical of several syndromes.
(c) Epicanthal folds.
(i) Vertical fold of skin at inner canthus of eye on either side of the nose.
(ii) Common in trisomy 21.
(iii) Manifestation of in utero compression (Potter facies).
(d) Eyelashes, eyebrows.
(i) Appear at 20 to 23 weeks.
a) Absent lashes or long lashes.
b) High-arched eyebrows or synophrys (meeting of eyebrows in middle).
Assessment of nose
(1) Shape and size.
(a) Positional deformities often due to birth process; resolve without treatment.
(b) Abnormal shape: may be associated with a congenital syndrome.
(c) Abnormal: flat, broad nasal bridge.
(2) Patency of nostrils.
(a) Place a cold, metal object under each nostril and observe for fogging: presence of airflow.
(b) Causes of nasal obstruction.
i) Choanal atresia or stenosis: membranous or bony obstruction; unilateral or bilateral.
(ii) Iatrogenic: swollen mucosa from suction catheters.
(iii) Inflammation and secretions.
Assessment of mouth
Mouth, tongue, and perioral region.
(1) Mouth should be symmetric and positioned in the midline: (a) Microstomia: very small mouth; may be associated with trisomy 18.
(b) Macrostomia: large mouth; often associated with mucopolysaccharidosis, Beckwith-Wiedemann syndrome, or hypothyroidism.
(c) Suck and swallow develops at 32 to 34 weeks, and root and gag response at 36 weeks. They should be elicited during the examination.
(2) Cleft upper lip: can vary from a niche in the lip to a complete separation extending up onto the floor of the nose.
(3) Thin upper lip in association with flat philtrum: fetal alcohol syndrome.
(4) Soft and hard palate should be visually inspected, then palpated (Merritt, 2005):
(a) Presence of submucous or membranous clefts.
(b) Narrow or high arch palate may indicate a decrease in neuromotor activity or sucking in utero.
(5) Mucosal cysts.
(a) Epithelial or Epstein's pearls: small, white epidermal cysts commonly found on the hard and soft palates and on gum margins and disappear after a few weeks.
(b) Bohn nodule: equivalent to milia on the skin.
(c) Gingival or alveolar cysts.
(6) Dental eruptions and neonatal teeth.
(a) If mobile or poor root formation: generally removed.
(b) Consult with pediatric dentist; may be primary teeth
(a) Small lingual frenulum normal ("tongue tied").
(b) Short frenulum that limits tongue movement: abnormal; tip of tongue will form an inverted V shape.
(a) Large tongue (macroglossia): generally part of syndrome (Beckwith-Wiedemann).
(b) Large tongue can obstruct the airway.
(c) Protruding tongue: trisomy 21 and Beckwith-Wiedemann.
(9) Thrush: oral moniliasis: usually contracted from mothers with vaginal moniliasis at time of delivery.
(a) Lacy white material present on surface of oral mucous membranes.
(b) Does not wipe away with a cotton-tipped swab.
3. Observe other facial features.
a. Nasolacrimal ducts.
(1) Tears are rare until 2 to 4 months of age.
(2) Obstruction: visible mass.
4. Inspect facial skin.
a. Milia: 1-mm white or yellow papules without erythema; resolve spontaneously within first weeks of life.
b. Miliaria: clear, thin vesicles 1 to 2 mm that develop in sweat glands; primarily seen on forehead, scalp, and creases.
c. Lacerations, ecchymosis, abrasions from forceps.
d. Petechiae over head and neck: typically from nuchal cord, rapid second stage of labor.
e. Pits or sinus: facial cleft syndromes.
5. Observe for size of jaw and relationship to maxilla.
a. Micrognathia: abnormally small jaw with normal-sized tongue.
(1) May present serious airway problem.
(2) Seen in Pierre Robin, Treacher Collins, and de Lange syndromes.
Assessment of Ears
1. Note presence or absence of external ear.
2. Determine position and rotation.
a. Helix attaches to scalp at a point horizontal to the inner canthus of the eye.
b. Normal: 30% of pinna above imaginary line drawn from the inner canthi of the eyes toward the occiput and tragus (cartilaginous projection in front of the external meatus of the ear).
c. Cranial molding may distort landmarks; ears may appear low-set.
d. Low-set ears may be associated with various syndromes and chromosomal abnormalities.
3. Check for presence of ear canals; visualization of eardrums not typically necessary.
4. Examine for abnormal findings.
a. Microtia: disorganized or dysplastic ear.
(1) Associated with atresia of auditory meatus and conductive hearing loss.
(a) Lop ear: helix folded downward because of inadequate development of the antihelix.
(b) Cup ear: small cup-shaped ear.
b. Preauricular pits and sinus.
(1) Pinpoint openings at base of helix or front of tragus.
(2) Increased risk of congenital deafness and renal abnormalities.
c. Preauricular ear appendages (tags).
(1) Single or multiple; vary in size.
(2) Differentiate from accessory auricle or tragus.
(3) Consistently seen in Goldenhar syndrome: syndrome with wide range of facial, ear, and vertebral defects (Jones, 2005).
(4) Associated with urinary tract abnormalities (Kohelet and Arbel, 2000) and other brachial arch abnormalities: cleft lip, cleft palate, and hypoplasia of mandible.
Assessment of neck
1. Inspect and palpate neck.
a. Mass: note location.
(1) Most common: cystic hygroma.
(a) Multiloculated cyst arising from lymphatic channels typically located posterior to the sternocleidomastoid muscle and extending into the scapula and axillary and thoracic compartments.
(b) Can distort the anatomy of the airway.
(2) Thyroglossal duct cyst or branchial cleft cyst.
(1) Excessive skinfold extending from the mastoid process to the shoulders.
(2) Associated with Turner and Noonan syndromes and trisomy 21.
c. Torticollis: rotation limited due to constant position of head to one side.
2. Gently palpate neck and clavicles.
a. Crepitus: due to fractured bone ends rubbing together.
(1) Swelling, discoloration, or tenderness associated with fractured clavicle.
(2) Observe for asymmetric arm movement with the Moro reflex or signs of pain with manipulation
Assessment of Lungs
1. Review influencing factors: GA, timing of examination, intrapartum and delivery history, maternal drugs, and cool environment.
2. Inspect the shape and size of the chest (Fig. 7-8).
a. Compare size relationship of the thorax and abdomen.
b. Normal: round symmetric shape with the anterior-posterior diameter approximately the same as the transverse diameter.
c. Large or barrel-shaped chest: associated with air trapping and hyperinflation.
d. Pigeon chest or protrusion of sternum: associated with Marfan syndrome.
e. Chest wall itself depressed or funnel shaped: pectus excavatum; no clinical significance.
f. Short sternum: associated with trisomy 18.
g. Rib margins apparent in premature infants: thinner layers of muscle and fat.
a. Color: refer to C. General Appearance: Initial Impression, p. 133.
b. Respiratory rate and pattern.
(1) Should be evaluated at rest and before any manipulation.
(2) Rate: normal—40 to 60 breaths per minute, easy, unlabored and typically abdominal or diaphragmatic.
(3) Tachypnea: rate greater than 60 breaths per minute—lung pathology, cardiac disease, infection, overheating, fever, and pain.
(4) Bradypnea or shallow respirations: CNS depression.
(5) Periodic breathing: 5- to 20-second pauses without changes in color, tone, or heart rate.
(6) Apnea: cessation of breathing for more than 20 seconds. May be accompanied by bradycardia, change in muscle tone, or color change; apnea of prematurity, infection, respiratory insufficiency, gastroesophageal reflux.
(7) Slow, gasping respirations: respiratory failure and acidosis.
c. Depth and ease of respirations.
(1) Normal: irregular and varying depth.
(2) Chest pulled inward as abdomen rises with inspiration as a result of normal diaphragmatic excursion.
(3) Retractions: accessory muscles used.
(a) Note depth (minimal, marked).
(b) Subcostal, substernal: common after birth. Persistence may indicate respiratory problems.
(4) Nasal flaring retractions, tachypnea, and grunting—symptomatic of respiratory distress.
4. Auscultate breath sounds.
a. Compare and contrast each side of chest.
b. Presence of air entry: normal, fair, or poor.
c. Asymmetric breath sounds: pneumothorax, cystic adenomatoid malformation, or congenital diaphragmatic hernia (CDH).
d. Normal breath sounds: clear and equal, little differentiation between inspiration and expiration.
e. Adventitious breath sounds. (1) Crackles: fine or coarse, lower pitched, fine crackles heard on inspiration, often present after birth due to clearing lung fluid.
(2) Wheeze: high pitched usually heard on exhalation, reactive airway.
(3) Rhonchi: low pitched, arise from partial obstruction by mucus or secretions.
(4) Stridor: rough, harsh sound worse during inspiration, caused by reduced airway diameter (edema, mass, vascular ring).
(5) Diminished breath sounds: atelectasis, effusion, decreased air entry, poor respiratory effort.
(6) Peristaltic sounds: bowel sounds indicate CDH.
(7) Friction rub: pleural effusion.
Assessment of breast and nipples
Inspect breasts and nipples.
(1) Based on GA.
(2) Enlarged breasts: effects of maternal estrogen, transient.
(3) Unilateral redness or firmness indicates sepsis.
b. Location and symmetry: widespread nipples—distance between nipples more than 25% of full chest circumference; may indicate variety of conditions (Sansoucie and Cavaliere, 2007).
c. Number: supernumerary nipples; small, raised, pigmented areas vertical with main nipple line 5 to 6 cm below normal nipple; familial.
(1) Witch's milk.
(a) Milky discharge produced in response to maternal hormones.
(b) Lasts for several weeks to months.
(2) Purulent: mastitis due to staphylococcal infection.
Assessment of Heart and Cardiovascular System
Heart and cardiovascular system.
1. General considerations: congenital heart defects are associated with other congenital malformations, chromosomal defects, maternal medication or substance use (phenytoin [Dilantin], alcohol), maternal health or illness (diabetes), viral illness, and familial association.
2. Observe color.
3. Heart rate: normal range 120 to 160 beats per minute (bpm) varies with infant behavioral state. a. Bradycardia: rate less than 100 bpm. (1) May be associated with apnea, cerebral defects, vagal response, congenital heart block.
(2) Term infant in deep sleep can have heart rate of 80 to 90 bpm; should increase as infant awakens.
b. Tachycardia: more than 160 bpm sustained. (1) May be associated with respiratory distress, anemia, congestive heart failure, hyperthermia, shock, and supraventricular tachycardia.
c. Brief irregularities are common; identification of abnormality cannot be made by auscultation alone.
4. Location of point of maximal intensity.
a. Normal: lateral to midclavicular line at the 4th intercostal space.
b. Shift in location can indicate tension pneumothorax.
c. Right-side location: dextrocardia, CDH.
d. Observe precordial activity. (1) Within 6 hours of birth may be visible along left sternal border (Southgate and Pittard, 2001).
(2) Visible for longer periods in premature infants.
(3) Associated with congestive heart failure, heart disease, and fluid overload.
5. Auscultate heart sounds.
a. First heart sound.
(1) Accentuated at birth.
(2) Increase in intensity: patent ductus arteriosus, ventricular septal defect, tetralogy of Fallot, anemia, hyperthermia, and arteriovenous fistula.
b. Second heart sound.
(1) Sound produced by closure of aortic and pulmonary valves.
(2) No splitting of heart sound: pulmonary atresia, transposition of the great artery, or truncus arteriosus.
c. Muffled heart sounds: may indicate pneumopericardium, pneumomediastinum, or CDH.
6. Auscultate murmur: turbulence in blood flow (Fig. 7-9).
a. Can be innocent or pathologic (underlying cardiovascular disease).
b. Timing of appearance.
(1) First 48 hours of life: can be related to cardiovascular transition; should be followed up.
(2) Audible after transition complete: ventricular septal defect, turbulence in pulmonary arteries secondary to obstruction; severe outflow tract obstruction.
c. Location and radiation.
(1) Describe as interspace, midclavicular, midsternal, or axillary.
(2) Transmission: auscultate back or axilla.
d. Timing within cycle.
(1) Continuous: extends beyond second heart sound into diastole.
(2) Systolic ejection murmur: occurs before the first heart sound; ends at or before second heart sound; flow across pulmonary valve.
e. Loudness or quality.
(1) Grade 1: barely audible.
(2) Grade 2: soft but easily audible.
(3) Grade 3: moderately loud but no thrill.
(4) Grade 4: loud with thrill.
(5) Grade 5: loud; audible with stethoscope placed lightly on chest.
(6) Grade 6: loud; audible with stethoscope placed near chest.
7. Palpate pulses: strength and equality (upper to lower and side to side).
a. Brachial, radial, and palmar.
b. Femoral, popliteal, posterior tibial, and dorsalis pedis.
c. Grading scale (Vargo, 1996).
0: Not palpable.
+1: Very difficult to palpate; weak, thready, easily obliterated with pressure.
+2: Difficult to palpate; may be obliterated with pressure.
+3: Easy to palpate; not easy to obliterate with pressure; found in normal pulses.
+4: Strong and bounding; not obliterated with pressure; associated with patent ductus arteriosus.
d. Absent femoral: associated with coarctation of aorta.
8. Assess capillary refill or perfusion.
a. Press and release skin over abdomen until area blanches.
b. Count number of seconds until color returns to area.
c. Normal: less than or equal to 3 seconds.
9. Blood pressure (Fig. 7-10).
a. Depends on gestational age and chronologic age.
b. Differential greater than 20 mm Hg between upper- and lower-extremity blood pressure indicates obstruction (coarctation of aorta).
c. Blood pressure (BP) in lower extremities should be slightly higher than in the upper extremities.
Assessment of Abdomen
1. General considerations: review history for feeding intake, emesis, stooling, maternal medications affecting bowel function, maternal blood type, and intrauterine infection.
2. Observe abdomen: slightly rounded, soft, and symmetric. a. Scaphoid abdomen: abdominal contents in chest (diaphragmatic hernia). May appear slightly concave at birth, but will become distended as bowel fills with air.
b. Decreased abdominal tone or muscles in abdominal wall, with visible bowel loops and margins of spleen and liver (prune belly syndrome) (Woods and Brandon, 2007).
c. Distention: obstruction, infection, masses, or enlargement of an abdominal organ.
3. Observe for abdominal wall defect (Thigpen, 2007).
a. Etiology: disruption in migration of abdominal contents from the umbilical cord and defect in the development of abdominal wall musculature.
b. Omphalocele: abdominal contents usually covered with a membrane; umbilical cord inserts into sac; commonly associated with cardiac lesions, trisomy 13, trisomy 18, Beckwith-Wiedemann syndrome.
c. Gastroschisis: abdominal wall defect resulting in protrusion of abdominal contents not covered with a membrane. (1) Typically located to the right of midline.
(2) Abdominal contents often thickened, edematous, and matted as a result of exposure to amniotic fluid.
d. Umbilical hernia: bulge at umbilicus related to weakness in abdominal muscle.
4. Palpate gently for enlargement in liver or presence of masses.
a. Normal: liver edge 1 to 2 cm below right costal margin in midclavicular line.
b. Begin palpation in right lower quadrant and progress upward so liver edge will not be missed.
c. Enlarged liver: congenital heart disease, infection, hemolytic disease, and arteriovenous malformation.
d. A normal spleen is rarely palpable; palpable spleen more than 1 cm below left costal margin is abnormal.
e. Abdominal mass: most often of urinary tract origin.
5. Palpate kidneys and bladder.
a. Place one hand under the flank and palpate gently from above with the fingertips of the other hand.
b. Normal kidney in term infant is 4.5 to 5 cm from pole to pole.
c. Further evaluation needed: absence of palpable kidney or enlarged kidneys.
d. Bladder can be palpated 1 to 4 cm above pubic symphysis when urine present.
6. Auscultate for bowel sounds.
a. Absent or hyperactive bowel sounds may indicate obstruction.
7. Inspect the umbilical cord (Thigpen, 2007).
a. Important clues to fetal growth, development, and well-being.
b. Normal: bluish white, moist, and gelatinous.
c. Diameter of cord varies and is related to Wharton jelly.
(1) Supportive covering protecting the cord vessels from compression or occlusion.
(2) Increases with GA.
(3) Thin cord may reflect placental insufficiency and intrauterine growth restriction.
d. Total length of cord: normal 30 to 90 cm. (1) Length determined by intrauterine space and fetal activity.
(2) Infants with limited fetal activity (Down syndrome, congenital neuromuscular disorders) have short cords.
e. Presence of knots.
f. Color: green or yellow (meconium); red (blood); depth of staining correlates with duration of exposure.
g. Number of vessels.
(1) Normally contains two arteries and one vein.
(2) Single umbilical artery may be associated with renal anomalies.
h. Urine draining from umbilicus: patent urachus (embryologic communication between bladder and umbilicus).
Assessment of Genitalia
a. Review pertinent history.
(1) GA; appearance changes with GA.
(2) Oligohydramnios or polyhydramnios: possible renal/urinary or gastrointestinal/pulmonary anomaly.
(3) Family history: associated genetic predisposition.
b. Congenital defects are relatively rare but highly stressful to parents.
c. Normal variations are more common than pathologic conditions.
d. Genitourinary anomalies are highly associated with other system disorders (see Chapter 33).
e. Breech deliveries can cause significant bruising and edema of genitalia and perineum.
f. No circumcision should be done in infants with epispadias, hypospadias, or chordee.
2. General inspection and palpation: position infant supine for examination.
a. Gender identification: if not clearly distinguishable, do not assign sex until further evaluation. Inform parents of ambiguity and need for further testing.
b. Anus: locate position in relation to genitalia and determine patency.
(1) Anal opening: approximately midline.
(2) Slightly more anterior to genitalia in females.
(3) Check for anal wink in any infant suspected of neural tube defect; stroke anal opening lightly; observe positive constriction.
c. Passage of meconium; ensures open communication only.
(1) Fistulas: anteriorly or posteriorly placed; may be accompanied with bowel distention. (a) Rectovaginal fistula (female) or rectoperineal fistula (male).
(2) Constant dribbling of loose stool: suspect neural tube defect.
d. Inguinal area (Parker, 2007).
(1) Assess for hernia(s) when inguinal mass observed.
(2) Groin bulge: may be unilateral or bilateral; increase in size with crying or straining or spontaneously reduce.
(3) Palpate from lower abdomen along the inguinal canal to the labia or scrotum.
(4) Attempt to gently compress bowel back toward abdomen. Irreducible hernias are at high risk for incarceration and subsequent necrosis.
3. Male. a. Penis: inspect size, appearance, and foreskin. (1) Normal.
(a) Straight, may be erect.
(b) Size proportionate to body, average term length 2.5 to 3.5 cm from pubic bone to glans tip (Goodwin and Caldamone, 2005).
(c) Glans covered by prepuce (foreskin) in uncircumcised infant.
(d) Physiologic phimosis: tight, nonretractable foreskin; does not retract until 2 to 3 years of age.
(e) Prepuce: foreskin or fold of skin over the glans. (i) Amount and distribution: hooded (appearance of distal foreskin).
(ii) Small, white epithelial cysts on distal prepuce.
(2) Abnormal. (a) Chordee: curving or bowing of penis; sometimes occurs in conjunction with hypospadias.
(b) Micropenis: less than 2.5 cm in the term neonate.
b. Determine position of urinary meatus.
(1) Normal: midline at the glans tip.
(a) Hypospadias (Stokowski, 2004):
(i) Urethral opening located at the ventral surface of the penis; associated with chordee, meatal stenosis, inguinal hernia, and undescended testes.
(ii) May be blind dimple or pit in the glans at expected location of meatus
(b) Epispadias: urethral opening located on the dorsal surface of the penis.
c. Urine: observe strength, direction of stream, and color.
(a) Straight, forceful, and continuous stream.
(b) Most newborns void within first 24 hours of birth.
(c) Uric acid crystals (flaky, rust colored) are a normal variant.
(a) Altered stream direction may indicate urinary obstruction; urine from perineum or abdomen indicates urinary fistula.
(b) Abnormal color: red (hemoglobin or myoglobin), brown (bilirubin), brown-yellow (concentrated).
d. Scrotum and testes: inspect for size, symmetry, color, presence of rugae, and location of testes.
(a) Firm, smooth testes of equal size palpable in scrotal sac; undescended testes in inguinal canal normal for preterm infants.
(b) Darker skin pigmentation.
(2) Abnormal: scrotal swelling or discoloration, nonpalpable testes.
(a) Cryptorchidism, extrascrotal testes position—needs further investigation with ultrasound and karyotyping.
(b) Nonpalpable testes: if not detected in phenotypic male, evaluate for virilizing adrenal hyperplasia.
(c) Bifid scrotum: deep midline cleft in the scrotum.
(d) Hydrocele: unilateral or bilateral fluid collection in scrotal sac, + transillumination.
(e) Testicular torsion: blue discoloration, palpable firm mass, tender or nontender, − transillumination. May be surgical emergency.
a. Labia and clitoris: separate labia and exert gentle downward traction to evaluate structures.
(1) Normal: smooth, wrinkling with weight loss, hyperpigmented from hormonal influence.
(2) Edematous at birth due to maternal hormones.
(3) Perineum is smooth, no dimpling; fingertip width.
(a) Labia bulge may indicate inguinal hernia or ectopic ovary.
(b) Labioscrotal fusion, female virilization.
(c) Clitoromegaly, pseudohermaphroditism.
(d) Genitourinary (GU) anomalies: abnormal spacing between orifices.
(e) Rugae: ambiguous genitalia.
(1) Normal: pink, patent.
(a) White or blood-tinged discharge due to hormonal influence (pseudomenstruation); can persist 2 to 4 weeks.
(b) Redundant hymen tissue and vaginal skin tags are common.
(2) Abnormal. (a) Rectovaginal fistula: feces from vagina, indicates rectovaginal fistula.
(b) Imperforate hymen: secretions pool in vagina; can be confused with enlarged Bartholin cysts.
(c) Hydrometrocolpos: membrane covering vaginal opening causes uterine enlargement and pooling of vaginal secretions; seen as perineal or suprapubic mass.
c. Urethral meatus. (1) Normal position: below clitoris; often obscured by hymen.
(2) Abnormal: anterior displacement.
5. Intersex conditions.
Assessment of back and extremities
a. Influencing factors: GA, maternal hormones, in utero position, delivery mode/history, and timing of examination.
b. Many abnormalities are deformations from compression and contracture in utero rather than congenital defects.
c. Review for relevant history (Brand, 2007).
(1) Elevated maternal alfa-fetoprotein (neural tube defects).
(2) Maternal diabetes mellitus (sacral agenesis).
(3) Maternal deficiency folic acid or zinc; use of anticonvulsant medication.
(4) Decreased fetal movement (congenital neuromuscular disorders).
(5) Postnatal S. aureus sepsis (risk for osteomyelitis).
(6) Family history (hip dysplasia).
2. Observe infant at rest: appropriate number of limbs and digits; size and symmetry of upper and lower extremities; movement, position of comfort, range of motion, and trauma.
3. Palpate for joint or bone swelling, tenderness, or crepitus.
4. Back: position infant prone. a. Inspect for symmetry of sides, scapula position and symmetry, spine alignment and integrity, and presence of dermal lesions over spine or masses.
b. Inspect skin. (1) Mongolian spots. (a) Normal variant; macular gray-blue lesions from melanocyte concentration in dermis.
(b) Most commonly in lumbosacral region but can be found on legs, back, and shoulders.
(c) Occurs more often in black, Hispanic, Asian, and Native American infants.
(d) Benign; fade during childhood.
(2) Subtle cutaneous findings can indicate hidden spinal defects; observe for sacral pits or dimples, sacral tracts (pilonidal cysts), skin tag, abnormal hair distribution or hair tufts, unusual pigmentation, hemangiomas, or lipomas (Brand, 2007).
(3) Asymmetry of gluteal fold: suggests underlying mass (lipoma) or tethered cord (Brand, 2007).
c. Congenital spine defects.
(1) Closed spinal dysraphism (Brand, 2007).
(a) Spinal lipoma.
(b) Dermoid tumor.
(c) Tethered cord.
(d) Split cord malformation.
(e) Skin tags and appendages, human tail.
(f) Dermal sinus tract
(2) Neural tube defect.
(a) Failure of posterior neural tube closure (see Chapters 34 and 35Chapter 34 Chapter 35).
(b) Defect can be open, with spine and nerves exposed or covered with skin or tissue.
(3) Sacrococcygeal teratoma: tumor (mainly benign).
(4) Scoliosis: lateral spine curvature; evaluate for associated GU tract anomalies.
a. Upper extremities.
(1) Absent humerus, radius, or ulna: associated with syndromes.
(2) Clavicle or humerus fractures: associated with birth injury or osteogenesis imperfecta.
(3) Blisters on hands or forearms: in utero sucking.
(4) Brachial plexus injury: stretching or tearing of nerve roots by lateral traction on shoulder during birth (Volpe, 2008); or pressure from the maternal sacral promontory during fetal descent (Jennet et al., 2002). (a) Erb palsy ("waiter's tip"): paralysis of arm with intact grasp; asymmetric Moro reflex.
(b) Klumpke paralysis: forearm paralysis with absent grasp.
(c) Total brachial plexus injury; because the neonate cannot move the shoulder, the arms remain extended and turned inward, with the flaccid hand suggesting a "waiter's tip" hand.
(5) Observe the shape of hands and digits.
(a) Syndactyly: webbing between adjacent digits of hands.
(b) Polydactyly: supernumerary digits.
(c) Clinodactyly: congenital deviation of digits.
(d) Brachydactyly: shortened digit from shortened finger joint; normal variant; associated with achondroplasia and trisomy 21.
(6) Simian crease: single palmar crease; normal variant, positive finding in less than 50% of trisomy 21 infants (Sansoucie and Cavaliere, 2007).
(7) Nails: yellowing from meconium or postmaturity; dysplasia with chromosomal defects.
b. Buttocks. (1) Observe for blanching or cyanosis of extremities or buttocks while umbilical catheters in use; indicates circulation compromise and potential necrosis.
(2) Dimple on buttocks can indicate congenital anomaly of femur (Fletcher, 1998).
(1) Positional hip abduction: persistent joint flexion or contraction with knee extension resulting from prolonged breech position in utero.
(2) Developmental dysplasia of the hip (Witt, 2003).
(a) Asymmetric creases of buttocks and thighs due to shortened adductor muscles.
(b) Uneven knee level (positive Galeazzi sign) when positioned prone with feet level and knees at a 90-degree angle.
(c) Ortolani maneuver: detects dislocated hips.
(d) Barlow maneuver: determines dislocatable hips (Fig. 7-11).
d. Lower extremities.
(1) Legs normally slightly bowed with everted feet.
(2) Genu recurvatum: knee hyperextension; related to in utero position. (a) Usually found in breech position, females more often than males.
(b) Associated with Ehlers-Danlos, Marfan, Klinefelter, and Turner syndromes.
(c) Mild cases are benign; severe cases may require splinting/casting.
(3) Limb or digit amputation (amniotic band syndrome).
(a) Strands of amnion can wrap around any digit or more frequently, a limb.
(b) Causes constriction and amputation.
(4) Metatarsus adductus (Furdon and Reu Donlon, 2002). (a) May be positional or structural.
(b) Convex shape to lateral border of foot (C shaped).
(c) Adduction at tarsal-metatarsal joint; wider space between first and second toes.
(5) Talipes equinovarus; clubfoot.
(a) May be positional or structural.
(b) Inversion deformity of heel (sole points medially), forefoot incurving and ankle in equinus posture (toes pointing down and heel pointing up).
(6) Talipes calcaneovalgus: related to intrauterine position; sole of foot is flattened against uterine wall.
(7) Rocker bottom feet: arch looks like rocker bottom.
a. Repeat examination of abnormal findings; assess changes over time.
b. Review history: familial, genetic, or neurologic diagnosis; birth trauma; difficult delivery; perinatal depression; maternal medication, alcohol, and/or drugs.
c. GA is an important consideration; responses of preterm infant are immature.
d. Timing and sequence of examination may alter the neurologic examination (Volpe, 2008).
(1) Optimal timing for older newborns is about two thirds between feedings.
(2) Clinical condition may necessitate exclusion of parts of examination.
2. Observe for skin lesions related to neurologic disorders (Jones, 2005).
a. Neurofibromatosis: café au lait spots, greater than 1.5 cm in length or in numbers of six or greater.
b. Sturge-Weber syndrome: nevus flammeus noted unilaterally, following the trigeminal nerve tract on the face and possibly involving the upper trunk.
c. Tuberous sclerosis: areas of hypopigmented (white) macules on the skin.
3. Assess posture: assess infant in quiet awake, quiet active, or light sleep state(s); unswaddled; position supine with head midline.
a. Term infant lies with arms adducted, hips abducted and partially flexed, moderate flexion of all extremities, and with loosely clenched fists.
b. Preterm infant becomes more hypotonic with decreasing GA.
(1) Persistent neck extension (opisthotonos).
(2) Obligate thumb flexion (cortical thumb).
(3) Elbow flexion with dorsum of hands on bed.
(4) Frog-leg position at greater than 36 weeks of gestation.
4. Observe spontaneous movement.
a. Term infant moves limbs smoothly.
b. Preterm infant's movements may be jittery and jerky, with tremors.
c. Environmental stimuli or discomfort produces mass movements.
d. Coarse tremors and brief chin trembling are normal.
e. Jittery: rhythmic movements of equal intensity. (1) Occurs more after startle or crying.
(2) Distinguish between tonic and clonic seizures using gentle restraint: tremors will stop; seizures will continue.
5. Cry. a. Lusty, with normal pitch: normal term infant.
b. Weak or monotonous cry: depressed, ill, or preterm infant.
c. High-pitched cry: neurologic or metabolic abnormalities, drug withdrawal.
6. Tone. a. With decreasing GA, it may be more difficult to distinguish between random movement and true recoil.
b. Note weak, absent, or unequal responses.
c. Assess resistance to movement (passive tone).
(1) Limb recoil, heel-to-ear, scarf sign.
(2) Tendon reflex: only patellar reflex is reliable at birth; note sustained clonus.
d. Assess resistance to gravity (active tone).
(1) Traction response: pull-to-sit, ventral suspension; note degree of resistance.
(2) Ventral and horizontal suspension.
a. Developmental reflexes (primitive reflexes): should be elicited in the normal term infant. Note any exaggerated or absent responses.
(1) Sucking reflex: gently stimulate lips; infant opens mouth and begins to suck.
(a) Evaluate the coordination and strength of the suck with a gloved finger.
(b) Present at birth even in the premature infant, although it is not as strong as at term.
(2) Rooting reflex: stroke cheek: infant turns head and opens mouth toward the stimulated side.
(3) Palmar grasp: stroke the infant's palm with finger; infant will grasp the finger.
(a) Attempts to remove the finger will elicit a tighter grasp.
(b) Grasp should be equal bilaterally.
(4) Tonic neck reflex (fencing position).
(a) Position the infant supine. Turn the infant's head to one side.
(b) The infant will extend the upper extremity on the side where the head is turned and flex the opposite upper extremity.
(5) Moro reflex (startle reflex): "head drop" method preferred depending on the infant's condition (Sniderman and Taeusch, 2005). The high-risk neonate can be startled by making a loud noise close to the ear and noting the response.
(a) Hold infant supine in a neutral position several inches off the bed.
(b) Hold one hand behind the upper back and other supporting head. Infant's arms should cover the chest.
(c) Head is held midline and dropped back 1 cm with supportive hand.
(d) Infant will partially abduct shoulder, extend, and then smoothly adduct arms.
(i) Evaluate arm responses only.
(ii) Repeat two or three times as needed for detailed observation.
(iii) Asymmetric response may indicate brachial plexus injury.
(6) Stepping reflex: Hold the infant upright, allowing the soles of the feet to touch a flat surface; infant will alternate stepping movements.
(7) Babinski reflex.
(a) Stimulate sole of foot; infant will either flex or extend toes.
(b) Persistent absence of reflex can indicate CNS depression or spinal nerve dysfunction.
b. Spinal reflexes.
(1) Truncal incurvation reflex (Galant reflex).
(a) Hold infant in ventral suspension.
(b) Apply firm pressure along the side parallel to spine.
(c) Infant should flex pelvis toward the stimulated side.
(d) Indicates T2-S1 innervation.
(2) Anocutaneous reflex (anal wink).
(a) Stimulate perianal skin.
(b) External sphincter constricts.
(c) Indicates S4-5 innervation.
8. Cranial nerves.
a. Olfactory (I).
(1) Not usually assessed in newborns.
(2) Can attempt in infants with strong scents such as clove or peppermint placed under nose; evaluate for sniffing, grimace, or startle reflex.
b. Optic (II).
(1) Evaluate visual acuity and fields by using tracking methods.
(2) Watch for wandering or persistent nystagmus.
(3) Check pupils for size and constriction in response to light.
c. Oculomotor (II), trochlear (IV), and abducens (VI) nerves: supply pupils and extraocular muscles.
(1) Observe pupil response to light.
(2) Evaluate eye size and symmetry.
(3) "Doll's-eyes" test (vestibular response): move infant's head from side to side, eyes should move away from the direction of rotation.
(4) Fixed position or movement in same direction may indicate brainstem or oculomotor dysfunction.
d. Trigeminal nerve (V): supplies sensory nerves of jaw and face. (1) Touch the cheek; infant will demonstrate rooting reflex.
(2) Place a gloved finger in the infant's mouth to evaluate sucking and biting reflex.
e. Facial nerve (VII): controls facial expression.
(1) Observe for symmetric movement of the face.
(2) Inability to wrinkle brow or close eyes with crying indicates injury.
f. Auditory nerve (VIII): tested only grossly without proper auditory equipment (see 9, Sensory Function Responses).
g. Glossopharyngeal nerve (IX): evaluate and inspect tongue movements and elicit gag reflex.
h. Vagus nerve (X): supplies the soft plate, pharynx, and larynx. (1) Listen to cry: determine the presence or absence of stridor, hoarseness, or aphonia.
(2) Evaluate infant's ability to swallow.
i. Accessory nerve (XI): supplies neck muscles (sternocleidomastoid and trapezius).
(1) Turn infant's head from midline to one side.
(2) Infant should attempt to bring head back to midline.
j. Hypoglossal nerve (XII): supplies tongue muscles. Evaluate suck, swallow, and gag reflexes.
9. Sensory function responses.
(1) Painful stimulus to a foot elicits a withdrawal reflex.
(2) Touch sole of the foot with a pin to provoke flexion of the limb and extension of the contralateral limb.
(3) Absence of flexion in the stimulated leg is abnormal.
b. Light: shining a penlight into the infant's eye results in eyelid closure.
(1) Ring a bell sharply within a few inches of the infant's ear while the infant is lying supine.
(2) Response is based on observable attentiveness to the sound.
(3) A brainstem auditory evoked response is recommended in the newborn period for all infants.
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