Newborn Assessments

A newborn should have a thorough assessment by a provider within 24 hours of life. This assessment should include a review of the pregnancy, previous pregnancies, mother’s history, and prenatal screenings. Before this complete assessment by a provider, the RN is the first to assess the baby and should be able to provide a comprehensive assessment to identify any immediate issues that need to be addressed.

Immediately at delivery, the RN will assess the newborn for any problems transitioning to extrauterine life. This assessment is quick and may lead to the initiation of newborn resuscitation. The Apgar scores are assigned to the baby at 1 and 5 minutes of life by the RN or the provider caring for the newborn. The Apgar score assigns numbers based on the newborn’s heart rate, respiratory effort, muscle tone, reflex irritability, and color. These scores can range from 0 to 10 based on the assessment (AAP, 2015).

The transition period of the newborn is 4 to 6 hours of birth, when the newborn should adjust to extrauterine life. During this time, the newborn should be assessed every 30 to 60 minutes for temperature, respiratory rate, heart rate, color, and tone (Overview, 2020). A normal newborn heart rate is 120 to 160 beats per minute, and a normal respiratory rate is 40 to 60 breaths per minute. A temperature of ≥ 100.4°F is generally considered a fever. During this time, the newborn should have a full assessment done by a Registered Nurse. After this period, the healthy full-term infant should be assessed every 8 to 12 hours.

Each newborn should receive prophylactic eye care (usually erythromycin ointment) to prevent neonatal gonococcal ophthalmia and vitamin K intramuscular (IM) injection from preventing vitamin K deficient bleeding (AAP, 2018: Witt et al., 2016).  a Hepatitis B vaccination, screening for congenital hearing loss and metabolic and genetic disorders. Some states also require screening for critical congenital heart disease. Erythromycin and Vitamin K are usually given within 2 hours of birth. Parents who refuse should receive education about the importance of these treatments. The Hepatitis B vaccine is usually given within 24 hours of birth, and infants born to mothers who are HBsAg-positive should also receive hepatitis B immunoglobulin (HBiG) shortly after birth (within 12 hours) (CID, 2017).

The universal newborn hearing screen should be performed to check for hearing loss so that early intervention can be started if there is a problem. Metabolic and genetic screening is recommended for all newborns while in the hospital. Early intervention for these diseases can improve outcomes. Critical congenital heart disease screening is a simple pulse oximetry test that can detect problems (AAP, 2017b). It is also recommended that all infants are screened for hyperbilirubinemia during their hospital stay. This screening can be done by a blood serum level or a transcutaneous bilirubin test (AAP, 2017b). Weight loss of the infant should be monitored while in the hospital. It is normal for infants to lose up to 10% of their body weight, but greater than 10% weight loss requires an evaluation of feeding and support for the mother. Glucose screening should be performed on infants that meet the criteria of each hospital’s policy. Minimally, infants who are a gestational age (GA) < 37 weeks, infants who are large for gestational age (LGA) or small for gestational age (SGA), infants of diabetic mothers, and infants with a family history of genetic hypoglycemia need to have glucose screening (AAP, 2017b).

There are risk factors that have the potential to impact the well-being of a neonate. These risk factors include:

• Maternal diabetes - can put the newborn at risk for hypoglycemia.
• Maternal substance abuse - puts the newborn at risk for withdrawal.
• A positive group B strep culture, any infection during labor such as chorioamnionitis, or ruptured membranes > 18 hours, puts the newborn at risk of sepsis.
• Genetic or inherited diseases, such as Down syndrome, can risk the neonate.
• Small for gestational age or large for gestational age, infants are at risk of hypothermia, hypoglycemia, and feeding issues.
• Preeclampsia, or any other condition that can affect the placenta.

The gestational age may put an infant at risk. Preterm infants (gestational age (GA) below 37 weeks), including those born late preterm (GA 34 0/7 to 36 6/7 weeks), are at increased risk for morbidity and mortality compared with term infants (GA 39 to 42 weeks) (Overview, 2020).

A full newborn nursing assessment should include measurements such as weight, length, head circumference, and vital signs. The assessment should start by generalizing the infant’s appearance, including position, movement, color, and breathing (Overview, 2020). During this general observation, the RN should identify any apparent deformities, how the baby moves, 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 (Reginatto et al., 2017). 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 and 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 area 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 blood collections 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 (UpToDate, 2019). 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 ensure they are parallel to the eyes and not a common set, indicating a problem. The nose should be assessed for patency. The mouth should be examined for any cleft or abnormality. This examination 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 ensure it is clean without any signs of infection, such as redness or discharge.

The genitalia should also be observed. The size and location of the labia, clitoris, meatus, and vaginal opening should be assessed in the female infant. The labia minora and clitoris are prominent in preterm infants, while the labia majora becomes larger as the infant approaches the term. A male infant should evaluate the presence of testes, size of the penis, appearance of the scrotum, and the position of the urethral opening. 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 the abnormal ventral placement of the urethral opening is hypospadias. A newborn with hypospadias should not have circumcision and should see a urologist. The anus is examined for patency. 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 ensure 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 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 (Assessment, 2019).

The newborn provider should perform a full exam on a newborn within 24 hours of birth. Any abnormal findings should be reported to the provider when they are found. Some problems, as mentioned above, need immediate evaluation by a pediatrician or neonatologist who is available.

Nurses caring for newborns must know how to provide a complete, thorough assessment of the newborn. It can be easy to miss something minor, but if the nurse understands what is normal, he or she will be able to identify the abnormal.

The nurse assesses an infant who is 20 hours old at 3 am postpartum. The infant initially breastfed well during the first 8 hours of life but has not had a good feed in the past 12 hours. The infant has been getting fussier and is now inconsolable. The heart rate is 172, respiratory rate 66, and temperature is 98.9°F. The mom states that the baby will not latch and feed, even though he did earlier. The baby has voided but has not passed any meconium. The nurse notices during her assessment that the baby’s abdomen is distended, and the skin appears shiny. The rest of the baby’s assessment is normal.

What could this be? What should the nurse do?

• This case could be an infant with an imperforate anus because the baby has not passed meconium and has a distended abdomen. The infant is starting to exhibit signs of distress, with an elevated respiratory rate. This sign is an urgent scenario that a provider needs to assess immediately. This infant will need to go to the NICU and need treatment immediately.

• American Academy of Pediatrics Committee on Fetus and Newborn. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. The Apgar Score. Pediatrics 2015; 136:819.
• American Academy of Pediatrics. Prevention of Neonatal Ophthalmia. In: Red Book 2018 of the Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, Ill 2018. P. 1046.
• American Academy of Pediatrics; (2017b). Guidelines for Perinatal Care. Elk Grove Village, IL: 2017.
• Assessment of neonatal pain - UpToDate. Updated December 3, 2019. Accessed January 17, 2020. Visit Source.
• Committee on Infectious Diseases, Committee on fetus and newborn. Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 hours of birth. Pediatrics 2017; 140.
• Overview of the routine management of the healthy newborn. Accessed January 16, 2020. Visit Source.
• Reginatto FP, DeVilla D, Muller FM, et al. Prevalence and characterization of neonatal skin disorders in the first 72h of life. J Pediatr (Rio J) 2017; 93:238.
• UpToDate. Updated July 29, 2019. Accessed January 17, 2020. Visit Source.
• Witt M, Kvist N, Jorgensen MH. Prophylactic Dosing of Vitamin K to Prevent Bleeding. Pediatrics 2016; 137.