immediate and transition assessment of newborn with illustrative pictures. made easy to understand.

1. NEWBORN
ASSESSMENT

2. RISK FACTORS
An understanding of the maternal/fetal risk
factors is important for the anticipation of
possible problems that the infant may
experience. Risk factors may be divided into
two categories:
• those that can be modified, such as
smoking and drug use,
• and those that are inherent, such as
diabetes and pre-eclampsia.

3. IMMEDIATE POST-
BIRTH CARE
• Maintain ABCs
• maintain a warm, or thermoneutral,
environment
• Administration of vitamin K intramuscularly
• Breast feeding
• Care of skin

4. Immediate Care of
the Newborn
• Ensure a Patent Airway
– Position on side
– Suction mouth then nares
– supply warmed oxygen if necessary

5. Clamping of the Cord
• Cord should be clamped
off about 1” from base of
cord.
• Inspect the cord for
2 arteries and 1 vein.

6. Maintain Body
Temperature
• Dry off with prewarm towel
• Skin to skin contact
• Place in warmer if needed

7. • Immediate assessment with
APGAR score
• The transitional assessment during
period of reactivity
• Physical assessment
• Gestational age assessment
Phases of Newborn
Assessment

8. IMMEDIATE ASSESSMENT
with apgar scoring

9. • In 1953, an anesthesiologist named Virginia
Apgar designed a tool for evaluating newborn
infants. The Apgar scores grade the infant's
response to extrauterine life in five categories
• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability
• Color

11. APGAR Score
SIGN SCORE-0 SCORE-1 SCORE-2
Heart Rate Absent Slow,<100 >100
Respiratory
Effort
Absent Irregular, slow
weak cry.
Good Strong Cry.
Muscle tone Limp Some Flexion of
Extremities
Well Flexed.
Reflex
irritability
No Response Grimace. Cry, Sneeze.
Colour Blue, Pale Body pink,
Extremities Blue
Completely pink.

12. APGAR scoring
is done in
1 & 5 min
• Total score of 0-3 represent severe distress ,
• Score of 4-6 signify moderate difficulty,
• Score of 7-10 absence of difficulty in adjusting
to extra-uterine life.

13. Score This !
• Baby girl Iva has a heart rate of 102,
with slow, irregular respirations. She
grimaces when stimulated. She has
some flexion in her extremities and her
skin color is pale.
• What is her Apgar Score?

14. 2+1+1+1+0 = 05
SIGN SCORE-0 SCORE-1 SCORE-2
Heart Rate Absent Slow,<100 >100
Respiratory
Effort
Absent Irregular, slow
weak cry.
Good Strong Cry.
Muscle tone Limp Some Flexion of
Extremities
Well Flexed.
Reflex
irritability
No Response Grimace. Cry, Sneeze.
Colour Blue, Pale Body pink,
Extremities Blue
Completely pink.

15. TRANSITIONAL
ASSESSMENT
• Assessment of newborn’s behavior during first
24 hours.
• Neonate tries to cope-up with extra-uterine life
• Various changes in vital function occurs & is
known as period of reactivity.
a) First period of reactivity (6 to 8 hours)
b) Second period of reactivity

16. The first period of
reactivity
• generally lasts 6 to 8 hours.
• For the first 30 minutes after birth, the newborn is generally very
alert and active.
• The infant will usually have a vigorous suck reflex during this time,
and it is generally an excellent time to begin breastfeeding.
• The infant will have open eyes and will be interested in looking
around.
• Physiologically, the infant's respiratory rate may be increased and
the lungs will sound quite wet.
• The heart rate may be increased, bowel sounds are active,
mucous production is increased, and body temperature may be
slightly decreased

17. • After this initial period of alertness, the newborn will go into
a deep sleep that generally lasts from 2 to 4 hours, though it
may continue much longer.
• During this period, the infant is very calm. Attempts to
stimulate the infant will generally be unsuccessful.
• Ideally, the physical examination should be completed
before this time and the infant can then be left alone to
sleep. Physiologically, the infant will experience a decrease
in respiratory rate, mucous production, and temperature
and will likely not void or stool

18. The second period
of reactivity
• Which usually lasts 2 to 5 hours, begins when the
newborn wakes from this deep sleep state.
• The infant is generally very alert once again and showing
signs of hunger.
• This is an excellent opportunity for the infant and family
to interact with each other and for the nurse to begin
some teaching regarding hunger cues and other ways
that the infant may communicate needs.
• Physiologically, the newborn's heart and respiratory rates
increase, the gag reflex is active, and the production of
mucous and meconium resumes

19. PHYSICAL
ASSESSMENT
• General Guide lines for conducting a physical examination
are:-
• Provide a normothermic and non- stimulating examination area.
• Undress only body area to be examined to prevent heat loss.
• Proceed in an orderly sequence(usually head to toe) with
following exceptions-
 Perform all procedures that require quiet first such as
auscultating the lungs heart and abdomen.
 Perform disturbing procedures such as testing reflexes, last.
 Measure head, chest and length at same time to compare to
compare results.

20. Contd….
• Proceed quickly to avoid stressing infants.
– Check that equipment and supplies are
working properly and are accessible.
• Comfort infant during and later examination,
Involve parent in the following - Talk softly.
- Hold infants hand against chest.
- Swaddle and hold.
- Guide pacifier and gloved finger to suck.

21. Identification of the
Newborn
 Mother and infant should have
matching “identitybands”.
 Bands should be placed on infant prior to
leaving the delivery room
 Footprint of infant and fingerprint of the
mother

22. PHYSICAL EXAMINATION
ARE CARRIED OUT AS
• Anthropometric measurements-
• Head circumference- 33 to 35 cm, about 3 cm
larger than chest Circumference.
• Chest Circumference- 3 cm less than the head
circumference.
• Crown to rump length- 31 to 35 cm
approximately equal to head circumference.
• Head to Heal Length- 50 ± 2cm
• Birth Weight- 2500 - 3000gm (6-9 pounds).

23. VITAL SIGNS
• Temperature-
- Axillary 36.5 °c - 37°c (97.9°F - 98°F)
- Crying may increase body temperature
slightly.
- Radiant warmer will falsely increase body
temperature.

24. Abnormal
(Possible causes)
• Decreased: cold environment,
hypoglycaemia, infection, CNS problem
• Increased: infection, environment too
warm

25. • Heart Rate-
- Apical 120- 140 beats / min. (assess pulse- femoral,
brachial, pedal )
- Crying will increase heart rate.
- Sleep will decrease heart rate.
- During the period of reactivity (6-8 hours) rate can
reach 180 beats / min
- PMI (point of maximal impulse) at 3rd – 4th intercostal
space

26. • Tachycardia: respiratory problems,
anemia, infection, cardiac conditions
• Bradycardia: asphyxia, increased ICP
• PMI to right : dextrocardia, pneumothorax
• Murmurs: functional or congenital heart
defects
• Dysrhythmias: absent or unequal pulses
(coarctation of aorta)
Abnormal
(Possible causes)

27. RESPIRATORY
• Before birth O2 needs met by placenta
• L/S ratio should be 2:1
• After delivery need mature lungs that are vascularized,
have surfactant and sacules - usually adequate by 32-35
weeks- at term the lungs hold approx. 20-30 ml of fluid/kg
• What initiates respiration?
• Respiration rate: 40-60/min
• Shallow & unlabored.
• Chest movement symmetric, breath sounds present &
clear bilaterally

28. • Tachypnea, especially after the first hour
• Slow respiration (maternal medication,
distress)
• Asymmetry or decreased chest expansion
(pneumothorax)
• Moist, coarse breath sounds rales,
crackles, rhonchi, fluid in lungs)
• Bowel sounds in chest (diaphragmatic
hernia)
Abnormal
(Possible causes)

29. Periodic Breathing -vs-
Apnea
• Apnea: no breathing for periods of greater
than 15 seconds should be evaluated.
Notify physician if resp < 30 or > 60

30. Assessment of
Respiratory Status

31. 0 1 2
Cyanosis None In room air In 40% FIO2
Retractions None Mild Severe
Grunting None
Audible with
stethoscope
Audible without
stethoscope
Air entry Clear Decreased or delayed Barely audible
Respiratory
rate
Under 60 60-80 Over 80 or apnea
Score:
> 4 = Clinical respiratory distress; monitor arterial blood gases
> 8 = Impending respiratory failure
Downes Scoring system

32. Cry
• Should be vigorous, medium pitched
• Piercing cry from :
Hypoglycemia
Neurological disorders
Sepsis
Withdrawal

33. • General appearance-
Posture –Flexion of hand and extremities
which rest on chest and abdomen .

34. Comparison of
resting posture

35. SKIN-
• Edema around eyes , face ,legs dorsa of hands ,
feet and scrotum or labia.
Assessment Normal finding Abnormal
finding
Note the skin
color and lesion
At Birth- Bright
red , puffy ,
smooth.
Second to 3RD day
Pink flaky ,Dry .
Vernix caseosa.
Lanugo .
Acrocyanosis-
Cyanosis of hands
and feet .
Color- cyanosis,
jaundice, pallor,
etc.

36. 36
General description of the skin

37. 37
Acrocyanosis

38. 38
1. Vernix Caseosa: Soft yellowish cream layer
that may thickly cover the skin of the
newborn, or it may be found only in the body
creases and between the labia.
The debate of wash it off or to keep it.

39. 39
Vernix Caseosa

40. 40
2. Lanugo hair:
- Distribution
- The more premature baby is, the heavier the
presence of lanugo is.
- It disappears during the first weeks of life

41. 41
Lanugo hair
Term baby preterm baby

42. 42
3. Mongolian spots:
Bluish black coloration on the lower back, buttocks,
anterior trunk, & around the wrist or ankle. They are
not bruise marks or a sign of mental retardation,
they usually disappear during preschool years
without any treatment.
They are caused by some pigment that didn't make
it to the top layer when baby's skin was being
formed.

43. 43
Mongolian spots

44. 44
Mongolian spots

45. 45
4. Desquamation:
- Peeling of the skin over the areas of bony
prominence that occurs within 2-4 weeks of life
because of pressure and erosion of sheets.

46. 46
Desquamation

47. 47
5. Physiological Jaundice:
6. Milia:
- Small white or yellow pinpoint spots.
- Common on the nose, forehead, & chin
of the newborn infants due to accumulations of
secretions from the sweat & sebaceous glands
that have not yet drain normally.
They will disappear within 1-2 weeks, they
should not expressed.

48. 48
Physiological Jaundice

49. 49
Physiological Jaundice

50. 50
Milia

51. Cutis Memorata – Transient mottling
when infant is exposed to decreased
temperature , stress or over stimulation.

52. HEAD-
• Anterior Fontenelle - Diamond Shaped , 2.5 –
4cm (1-1.75 inch ).
• Posterior Fontanelle –Triangular , 0.5 -1 cm (
0.2 – 0.4 inch ).
• -Fontenelle should be flat , soft and firm .
• -Widest part of fontenelle measured from bone
to bone , not suture to suture .
• Palpate fontanelle

54. • Anterior fontanelle • posterior fontanelle

56. Molding of infant's head.
Molding- over-riding sutures

57. 57
Caput succedaneum
• An edematous swelling on the presenting portion
of the scalp of an infant during birth, caused by
the pressure of the presenting part against the
dilating cervix. The effusion overlies the
periosteum with poorly defined margins.
• Caput succedaneum extends across the midline
and over suture lines. Caput succedaneum does
not usually cause complications and usually
resolves over the first few days. Management
consists of observation only.

58. 58
Caput succedaneum

59. 59
Caput succedaneum

60. 60
Caput succedaneum

61. 61
Cephalhematoma:
Cephalhematoma is a subperiosteal collection
of blood secondary to rupture of blood vessels
between the skull and the periosteum, in which
bleeding is limited by suture lines (never cross
the suture lines).

62. 62
Cephalhematoma

63. 63
Cephalhematoma

64. • Caput succedaneum
• crosses suture line
• Cephalahematoma
• does not cross suture

65. FACE
• Should be assessed for Symmetry,
paralysis, shape, swelling etc
• Any congenital disorder

66. Observe shape & size of mouth,
size of jaw
• Jaw molding
• micrognathia-
small jaw

67. EARS -
• Position – Top of pinna on horizontal line with outer
canthus of eye .
Symmetry
Low set r/t Down’s, mental retardation, renal problems
• Startle reflex elicited by a loud , sudden noise . Respond
to sound, Habituation
• Pinna flexible ,
• Hearing Test

68. Cartilage
Term Preterm

69. • Ear tag • Lop ear

70. • Microtia, small ear

71. EYES
• Bluish white sclera, pupils gray in color. True color is
not determined until the age of 3-6 months.
• Check reflexes
• Doll eyes, Blinking reflex, Can not follow an object
(Rudimentary fixation on objects).
• Tearless
• Some visual acuity
• Usually edematous eye lids
• Pupil: React to light
• Absence of tears

72. 72
Normal Eye

73. 73
Eyelid Edema

74. 74
Dysconjugate Eye Movements

75. 75
Subconjunctival Hemorrhage

76. 76
Congenital Glaucoma

77. Purulant discharge &
swollen eye lid in
gonorrhea and
Chlamydia

78. • Hypertelorism • Iris cyst

79. Cataract

80. NOSE-
• Nasal patency .
• Symmetry
• Nasal Discharge – Thin white mucus .
• Sneezing .

81. 81
Normal Nose

82. 82
Dislocated Nasal Septum/
deviated nasal septum

83. Any congenital defect-
• depressed nose
bridge (which is
indicative of
Down’s syndrome)
• dacrocystocele1

84. MOUTH & THROAT
• Assess sucking, swallowing, gag reflex.
• Uvula in midline .
• Absent or minimal salivation
• Check palate for any deformity
• Oral thrush

85. 85
Epstein Pearls & cheeks

86. 86
Cleft Palate

87. 87
Cleft Lip

88. 88
Cheeks: Have a chubby appearance
due to development of fatty sucking pads
that help to create negative pressure
inside the mouth which facilitates
sucking.

89. 89
Gum: May appear with a quite irregular edge.
Sometimes the back of gums contain whitish
deciduous teeth that are semi-formed, but not
erupted

90. 90
Irregular edges with Natal Teeth

91. 91
Natal Tooth

92. 92
Normal Tongue Ankyloglossia

93. 93
Ankyloglossia (tongue tie)

94. NECK –
• Short thick neck, usually surrounded by
skin folds . Sometimes associated with
widely separated nipple.
• Tonic neck reflex .

95. • Short neck with other anomaly

96. CHEST-
• Anterio- posterior and lateral diameters
equal.
• Xiphoid process evident.
• Milky discharge from nipples.
• Abnormal respiration sounds.

97. • Intercostals
retraction
• Breast
enlargement.

98. In this infant, the antero-posterior (AP) diameter appears greater
than normal, and there was concern that the AP diameter of the left
chest was greater than that on the right. (Notice the white lead on
the right nipple and the gold lead over the midline) This finding is
suspicious for pnuemothorax, which can occur spontaneously in
well newborns. Congenital diaphragmatic hernia may present with
an abdomen that appears flat relative to the chest (scaphoid
abdomen), but in that case severe respiratory distress would be
expected.

99. LUNGS-
• Respirations chiefly abdominal.
• Cough reflex absent at birth , present by 1-
2 days in term infant .
• Bilateral equal bronchial breath sounds.
• Apex- Fourth to fifth inter-coastal space
,lateral to left sterna boarder .

100. ABDOMEN –
• Cylindric in shape .
• Liver- Palpable 1-3 cm below right coastal
margin.
• Spleen - Tip palpable at end of 1st week of
age .
• Kidneys- Palpable 1-2 cm above umbilicus
• Femoral pulses – Equal bilaterally.
• Umblical Cord- Bluish –white at birth with
two arteries and one vein . Made of
wharton’s jelly

101. • umbilical hernia

102. • Normal umbilical
cord
• Meconium stained
umbilical cord

103. • normal cord has two arteries (small, round
vessels with thick walls) and one vein (a
wide, thin-walled vessel that usually looks
flat after clamping).

104. Dry cord
Normal cord with intravascular clots Cord after 19 hours
After shading

105. • Omphalitis umbilical
hematoma

106. Cord hemangioma can be quite
serious. Large hemangiomas can
comprise the vasculature or
completely obstruct flow in the
cord in utero or lead to high
output cardiac failure. Fetal
deaths have been reported.
• Wharton's jelly cyst
Also known as a "false
cyst" of the cord, is an
area where liquefaction of
the jelly has occured. Up
to 20% of infants with this
condition have associated
anomalies.

107. Gastrointestinal System
• Immature at birth, reaches maturity at 2-3
years of age
• place food at back of tongue
• sucking becomes coordinated @32 wks
• little saliva until 3 months of age
• bowel sounds after 1 hour of birth

108. Gastrointestinal (continued)
• NB have difficulty digesting complex
starches and fat
• Abdomen becomes easily distended after
eating
• Initial fecal material = meconium
• No normal flora at birth in GI system to
synthesize Vit. K

109. HEPATIC FUNCTION
• Liver produces substances essential for
clotting of blood.
• Stores needed iron for the first few
months. Preterm & small infants have lower iron stores than
full term and heavier infants. (full term infants stores last 4-6 mo)
• NB at risk for Physiologic Jaundice after
24 hours of age, d/t increased breakdown
of RBC’s and immature liver functioning.

110. Increased Bilirubin Levels
• Jaundice in the 1st day is NOT normal
• Bilirubin level greater than 12 at any time
needs further attention
• Maternal causes of increased bilirubin
levels in the NB: epidural use, oxytocin
induced labor, infection, hepatitis
• Ethnic Influences: Asian infants levels
may be double other ethnic groups.

111. Kernicterus
• Complication of neonatal
hyperbilirubinemia --> encephalopathy
• basal ganglia and other areas of the brain
and spinal card are infiltrated w/ bilirubin
(produced by the breakdown of
hemoglobin -> levels of 20 - 25 or more).
• Poor prognosis if untreated.

112. GENITOURINARY SYSTEM
KIDNEYS AND URINATION
• 92% of all healthy infants void in the first
24 hrs of birth
• initial urine:cloudy, scant amounts, uric
acid crystals-> reddish stain on diaper
• Kidneys not fully functional until child is 2
years of age.

113. FEMALE GENITALIA-
• Labia and Clitoris
usually edematous.
• Uretheral meatus
behind clitoris .
• Vernix caseosa
between labia.
• Urination within 24
hours .

114. • Normal female
genitalia
• Hymenal tag

115. MALE GENITALIA
• Uretheral opening at tip of glans
penis .
• Testes palpable in scrotum .
• Scrotum usually large ,
edematous , pendulus and
covered withrugae ,usually
deeply pigmented in dark –
skinned ethnic group
• Smegma .
• Urination within 24 hours .

116. • Hypospedias
• Epispedias with
extrophy of bladder
(ectopia vesica)

117. • Chordee

118. • Hydrocele • Inguinal hernia

119. • Inguinal or
descending testicle
• Undescended testis

120. • Ambiguous genitalia
• Male
• Ambiguous genitalia
• female

122. BACK AND RECTUM –
• Spine intact , no openings , masses or
prominent curves .
• Trunk incurvation reflex .
• Anal reflex .
• Patent and opening .
• Passage of meconium within 48 hours of birth
.

123. • Sacral dimple • Sacral skin tag
Skin tags in the
sacral area are also
potential indicators
of spinal dysraphism

124. • myelomeningocele

125. EXTREMITIES:-
• Ten fingers and toes .
• Full range of motion(ROM).
• Nail beds pink with transient cyanosis
immediately after birth.
• Sole usually flat.
• Symmetry of extremities Equal muscle tone
bilaterally , especially resistance to apposing
flexion .
• Equal bilateral brachial pulses.

126. • Normal palm
Creases
• Transverse palm
crease

127. • Club foot severe syndactyly

128. • polydactyly • Syndactyly

129. NEUROLOGICAL REFLEXES
• Primary reflexex
• Hypotonia

130. WEIGHT LOSS
• It is normal for the newborn infant to loose 5-
10% of weight in the first 4 to 5 days of life.

131. INFANTS AT RISK
“RED FLAGS” after birth include:
• gagging --> turning blue (esp. after fdg)
• generalized cyanosis
• weak cry
• grunting or respiratory distress
• decreased or absent movements
• excessive twitching or trembling
• OTHERS>>>>>

132. The following findings are
considered warning signs that
may be seen during the general
assessment
• Axillary temperature less than 36.1°C or greater than
37.2°C
• Heart rate less than 100 bpm or greater than 160 bpm
• Respiratory rate less than 30 or greater than 60 breaths
per minute
• Jaundice
• Periods of apnea lasting more than 15 seconds
• Lack of movement or responsiveness
• Hypotonic or hypertonic position
• Lack of interest in environment

133. • WARNING SIGNS
• Warning signs of the skin assessment that would warrant
further investigation and/or immediate intervention include:
• Long nails and desquamation, indicating postmaturity
• Thin translucent skin with abundant vernix and lanugo,
indicating prematurity
• Pallor, possibly caused by hypothermia, anemia, sepsis, or
shock
• Cyanosis, possibly caused by cardiorespiratory disease,
hypoglycemia, polycythemia, sepsis, or hypothermia

134. • Petechiae, possibly caused by thrombocytopenia, sepsis,
congenital infection, or pressure sustained during delivery
• Plethora, possibly caused by polycythemia
• Meconium staining, possibly caused by intrauterine asphyxia
• Abnormal hair distribution or extra skin folds, possibly
associated with genetic abnormalities
• Poor skin turgor associated with intrauterine growth
retardation and hypoglycemia
• Large hemangiomas, which may trap platelets within their
borders and cause thrombocytopenia
• Bullae or pustules, possibly caused by staphylococcal
infection

135. NURSING DIAGNOSIS:
• Ineffective Airway Clearance R/T excessive
oropharyngeal mucus
• Ineffective Thermoregulation R/T newborn
transition to extrauterine life
• High Risk for infection R/T maturational
factors, immature immune system
• PC: Hypoxemia PC: Hyperbilirubinemia
• (W) Beginning Integration of NB into Family
Unit

136. THANK YOU