A full newborn nursing assessment should include measurements such as weight, length, head circumference, and vital signs. The assessment should start by making a general observation of the infant’s appearance including position, movement, color, and breathing.2 During this general observation, the RN should identify any apparent deformities, how the baby is moving, their color while resting, and their respiratory effort (nasal flaring, grunting, retractions in the chest).
The skin should be assessed for abnormalities such as areas of abnormal pigmentation, congenital nevi, macular stains, or hemangiomas. Vesicles, bullae, and pustules in the newborn may be caused by infections, congenital disorders, or other diseases.7 Milia are white papules that resolve within a few weeks. These are the most common problem with the skin and are harmless.
The head should be assessed next, looked for symmetry. The fontanelles should be soft and flat. The sutures of the skull should be felt. There may be molding from the birth canal, but if this lasts longer than 2 to 3 days after birth, there may be a problem. Caput succedaneum is an area of edema on the head. This may be present at birth, crosses suture lines, and resolves within a few days. Cephalohematomas are collections of blood that are present in 1 to 2 percent of newborns. On palpation, they form a fluctuant mass that does not cross suture lines, which may increase in size after birth, and usually take weeks to months to resolve. Subgaleal hemorrhages are collections of blood between the aponeurosis covering the scalp and the periosteum. Subgaleal hemorrhages extend across suture lines but feel firm and fluctuant. Blood loss from these hemorrhages can be life-threatening and should be evaluated immediately.8 The face should be assessed for symmetry. The eyes should also be assessed for symmetry, spacing, and movement. The ears should be assessed for symmetry and to make sure they are parallel to the eyes and not low set, which can indicate a problem. The nose should be assessed for patency. The mouth should be examined for any cleft or abnormality. This includes palpation of the palette. A small jaw could also indicate a problem. The neck is palpated for masses and the clavicles are palpated for crepitus, which could indicate an injury.
The chest should be examined for size, shape, and symmetry. A malformed chest could indicate a problem. Retractions may be observed with respiratory difficulty. Breast size and location should be assessed. The lungs should be auscultated while the infant is quiet. Respirations should be observed and counted for a full minute. Heart rate should be assessed with a stethoscope while listening for murmurs. The femoral pulse should also be palpated.
The abdomen should be assessed for shape. Any abnormal distention should be reported to the provider, as this could indicate a problem with the infant. The umbilical cord is evaluated to make sure it is clean without any signs of infection, such as redness or discharge.
The genitalia should also be observed. In the female infant, the size and location of the labia, clitoris, meatus, and vaginal opening should be assessed. The labia minora and clitoris are prominent in preterm infants, while the labia majora becomes larger as the infant approaches term. The presence of testes, size of the penis, appearance of the scrotum, and the position of the urethral opening should be evaluated in a male infant. A newborn who has had a circumcision should be assessed for excessive bleeding or signs of infection. One or both undescended testicles should be reported to a provider. A male urethra with abnormal ventral placement of the urethral opening is hypospadias. A newborn with hypospadias should not have a circumcision and should see a urologist. The anus is examined for patency. An imperforate anus is not always visible. A baby who has not passed meconium and has a distended abdomen needs urgent evaluation by a provider. A small sacral dimple may be normal, but a larger dimple needs evaluation.
The extremities should be assessed for proper movement and to make sure there are 5 fingers on each hand and 5 toes on each foot. The hips should be evaluated. The Ortolani and Barlow maneuvers use adduction and posterior pressure to feel for dislocation, and abduction and elevation to feel for reduction.
Newborn pain should be assessed every time the newborn gets vital signs assessed and during a painful procedure, such as circumcision, according to hospital policy. This pain should be evaluated using a validated tool. There are many options available.9