- Axillary temperature 97.7°–99.3°F (36.5°C–37.4°C)
- Auscultate apical pulse for 1 full minute
- 110–160 beats per minute
- Respirations counted for 1 full minute
- 30–60 per minut
- REPORT:
- Sustained resting respiratory rate below 30 or above 60
- Decreased or increased body temperature (may be a sign of sepsis)
- Sustained resting heart rate below 100 or above 160
Extremities/Activity
- Newborn posture flexed
- Extremities equal length with full range of spontaneous motion
- Gluteal folds even
- Ten fingers and 10 toes without syndactyly or polydactyly
- Reflexes intact with expected response
- Moro (startle) reflex: clap your hands loudly or gently bump crib to elicit symmetrical “embrace” movement of infant’s arms
- Babinski: firmly stroke sole of foot to elicit upward movement of great toe and fanning out of other toes
- Tonic neck: turn infant’s face to one side to observe extension of arm on same side and flexion of opposite arm; known as “fencing position”
- Palmar grasp: place your finger in the infant’s palm to elicit curling of his or her fingers around your finger
- Femoral pulse intact and equal in strength/rate compared with brachial pulse
- REPORT:
- Poor muscle tone or asymmetry of muscle tone
- Failure to spontaneously move all extremities
- Decreased range of motion
- Chewing-like mouth movements combined with noticeable changes in eye and/or body movements (may represent neonatal seizures)
- Unequal knee height, leg length, or asymmetrical gluteal folds (suggestive of hip dysplasia)
- Unexpected response when testing reflexes
- Jitteriness of the extremities (may indicate conditions such as hypoglycemia, hypocalcemia, or drug withdrawal or may be a transient idiopathic finding)
Skin
- Color uniformly pink
- Normal variations
- Acrocyanosis
- Milia
- Lanugo
- Mongolian spot
- Telangiectatic nevi “stork bites”
- Erythema toxicum
- REPORT:
- Central or circumoral cyanosis (bluish color of mucous membranesmouth; indicates systemic lack of oxygen)
- Skin lesions, bruises, abrasions
- Jaundice
- Routinely assess all newborns for signs of jaundice
- Blanch skin; if jaundiced, will appear yellow after pressure is released
- Use bilirubinometer if available
- Progresses in a cephalocaudal direction (from top to bottom)
- If jaundice is present, notify primary health-care provider
- Report serum bilirubin laboratory findings
- Initiate phototherapy if ordered
- Have eye shields and diaper in place
Vital signs, including temperature per hospital protocol- Ensure adequate hydration
- Monitor and report repeat laboratory tests
Head and Neck
- Head round with slight molding or caput succedaneum (soft tissue swelling over large presenting area of skull)
- Anterior and posterior fontanels soft and flat (bulging fontanel normal with crying)
- Anterior fontanel is diamond-shaped
- Posterior fontanel is triangle-shaped
- Head held midline with ease of movement
- Trachea midline
- Head circumference > chest circumference
- REPORT:
- Sunken or bulging fontanels when infant is at rest (bulging fontanel may indicate hydrocephaly; sunken fontanel may indicate dehydration)
- Cephalhematoma (bulging of head that usually does not cross skull suture line and, because it is filled with blood, is more firm than caput succedaneum)
- Abrasion
- Restricted neck movement
Face
- Face symmetrical with rest and crying
- Eyes are symmetrical in size and shape; pupils equal; red reflex andcorneal reflex intact
- Nose is midline with nares patent; patency by occluding one nare at atime while assessing breathing
- Ears have top of pinna aligned with inner canthus of eyes; pinna well-formed and hearing intact
- Mouth
- Oral mucosa pink and moist; tongue mobile
- Hard and soft palate intact
- Strong suck; able to coordinate suck and swallow
- Tongue freely movable
- Reflexes present
- Rooting (infant turns head toward side of face that is stimulated)
- Sucking
- Gag
- Extrusion (infant pushes tongue outward when it is touched)
- REPORT:
- Absence of red reflex
- Purulent discharge of eyes immediately after birth
- Low-set ears
- Lack of response to sound
- Nasal flaring
- Cleft lip or palate
- Large, protruding tongue (possible Down syndrome)
- White patches in mouth (candidiasis)
- Absent rooting, suck, gag, or extrusion reflex
- Severe drooling and/or coughing or gagging (do not feed until condition is assessed)
Chest
- Respirations unlabored
- Chest rises and falls symmetrically
- Lung sounds clear bilaterally
- Clavicles intact
- Breast buds present with nipples prominent and symmetrical
- REPORT:
- Nasal flaring, chest retractions, or expiratory grunting
- Asymmetrical or adventitious breath sounds
- Chest circumference greater than head circumference
- Persistent cardiac murmur
- Asymmetrical Moro reflex
Abdomen/Genitals
- Abdomen round and soft without palpable masses
- Three-vessel umbilical cord with drying base
- Bowel sounds present
- First void within 24 hours
- May be rust-stained from uric acid crystals
- Meconium stool passed within 24 hours
- Female genitalia
- Labia majora covers minora
- May have mucoid vaginal discharge or pseudomenses
- Male genitalia
- Urinary meatus at tip of penis
- Testes descended with rugae present
- REPORT:
- Drainage of urine or feces from umbilicus
- Liver more than 3 cm below right costal margin
- Abdomen markedly distended
- Palpable abdominal mass
- Visible peristaltic waves
- Poor feeding or excessive spitting/vomiting
- Failure to urinate or pass meconium within 24 hours
- Hypospadias or epispadias (urinary meatus on ventral or dorsal side of penis)
- Mass in scrotal or inguinal area
- Imperforate anus
- Spine midline and straight, intact, and easily flexed
- Trunk incurvation reflex intact
- REPORT:
- Arched back
- Sinus or nevus with tuft of hair.
- Meningocele/myelomeningocele