Newborn Physical Assessment Findings

Posture:

Full-term neonate assumes symmetric posture; face turned to side; flexed extremities;
hands tightly fisted with thumb covered by fingers.
Asymmetric posture may be caused by fractures of clavicle or humerus or by nerve
injuries commonly of the brachial plexus.
Infants born in breech position may keep knees and legs straightened or in frog position,
depending on the type of breech birth.

Length:
Average length of full-term neonate is 50 cm; range, 46 to 54 cm.
Weight:
Average weight of male neonates is 3,400 g); female neonates, 3,200 g. Weight range of 80% of
full-term neonates is 2500 to 4,000 g.

Skin:
Examine under natural light for:

Hair distribution term infant will have some lanugo over back; most of the lanugo will
have disappeared on extremities and other areas of the body.
Turgor term infant should have good skin turgor; ie, after gently pinching small portion
of skin and releasing it, the skin should return to its original position.
Color
o Cyanosis acrocyanosis, bluish color in palms of hands and soles of feet, is
common because of immature peripheral circulation. This condition is
exacerbated by cold temperatures.
o Pallor may indicate cold, stress, anemia, or cardiac failure.
o Plethor reddish (ruddy) coloration may be caused by a high level of red blood
cells to total blood volume from intrauterine intravascular transfusion (twins),
cardiac disease, or diabetes in the mother.
o Jaundice physiologic jaundice caused by immaturity of liver is common
beginning on day 2, peaking at 1 week and disappearing by the 2nd week. It first
appears in skin over the face or upper body, then progresses over a larger area; it
can also be seen in conjunctivae of eyes.
o Meconium staining staining of skin, fingernails, and umbilical cord indicates
passage of meconium in utero (possibly caused by fetal hypoxia in utero).
Dryness/peeling marked scaling and desquamation are signs of postmaturity.
Vernix in full-term infants, most vernix is found in skin folds under the arms and in the
groin under the scrotum (in males) and in the labia (in females).
Nails should reach end of fingertips and be well developed in the full-term infant. There
should be no evidence of pits, ridges, aplasia, or hypertrophy.
Edema some edema may occur over buttocks, back, and occiput if the infant has been
supine; pitting edema may be caused by erythroblastosis, heart failure, and electrolyte
imbalance.
 Ecchymosis may appear over the presenting part in a difficult delivery; may also indicate
infection or a bleeding problem.
Petechiae pinpoint hemorrhages on skin caused by increased intravascular pressure,
infection, or thrombocytopenia; regresses within 48 hours.
Erythema toxicum (newborn rash) small white, yellow, or pink to red papular rash that
appears on trunk, face, and extremities; regresses within 48 hours.
Hemangiomas vascular lesions present at birth; some may fade, but others may be
permanent.
o Strawberry bright red, raised, lobulated tumor that occurs on the head, neck,
trunk, or extremities; soft, palpable, with sharp demarcated margins; increases in
size for approximately 6 months, then regresses after several years.
o Cavernous larger, more mature vascular elements; involves dermis and
subcutaneous tissues; soft, palpable, with poorly defined margins; increases in
size the first 6 to 12 months, then involutes spontaneously.
Telangiectatic nevi (stork bites) flat red or purple lesions most commonly found on the
back of the neck, lower occiput, upper eyelid, and bridge of the nose; regress by 2 years
of age, although the ones on the neck may persist through adulthood.
Milia enlarged sebaceous glands found on nose, chin, cheeks, brow, and forehead; regress
in several days to a few weeks. They appear as multiple yellow or pearly white papules,
approximately 1 mm in diameter. When found in the mouth, they are referred to as
Epstein pearls.
Mongolian spots blue-green or gray pigmentation on the lower back, sacrum, and
buttocks; common in Blacks (90%), Asians, and infants of southern European heritage;
regress by 4 years of age. May be mistaken for signs of child abuse.
Harlequin color change when on side, dependent half turns red, upper half pale; caused
by gravity and vasomotor instability.
Abrasions or lacerations can result from internal monitoring and instruments used at
birth.
Cutis marmorata bluish mottling or marbling of skin in response to chilling, stress, or
overstimulation.
Port wine nevus (nevus flammeus) flat pink or reddish purple lesion consisting of dilated,
congested capillaries directly beneath the epidermis; does not blanch.

Head:

Examine head and face for symmetry, paralysis, shape, swelling, movement.
o Caput succedaneum swelling of soft tissues of the scalp because of pressure;
swelling crosses suture lines. Associated with vacuum-assisted birth.
o Cephalohematoma: subperiosteal hemorrhage with collection of blood between
periosteum and bone; swelling does not cross suture lines. May result from
vacuum-assisted birth (use of the vacuum extractor).
o Molding: overlapping of skull bones, caused by compression during labor and
delivery (disappears in a few days).
o Examine symmetry of facial movements.
o Forceps marks: U-shaped bruising usually on cheeks following forceps delivery.
 Measure head circumference: 33 to 35 cm, approximately inch (2 cm) larger than
chest. Measure just above the eyebrows and over the occiput.
Fontanelles: area where more than two skull bones meet; covered with strong band of
connective tissue; also called the soft spot.
o Enlarged or bulging: may indicate increased intracranial pressure (ICP).
o Sunken: commonly indicates dehydration.
o Size: posterior may be obliterated because of molding; generally closes in 2 to 3
months. Anterior is palpable; generally closes in 12 to 18 months.
Sutures: junctions of adjoining skull bones.
o Overriding: caused by molding during labor and delivery.
o Separation: extensive separation may be found in malnourished infants and with
increased ICP.

Face:

Eyes examine the following:

o Color sclera in most full-term infants are white; blue sclera is indicative of
osteogenesis imperfecta. Eye color usually slate-gray, brown, or dark blue; final
eye color is evident by 6 to 12 months.
o Hemorrhagic areas subconjunctival hemorrhages may appear as a red band from
pressure during delivery; regress within 2 weeks.
o Edema of the eyelids may be caused by pressure on the head and face during
labor and delivery.
o Conjunctivitis or discharge may be caused by instillation of silver nitrate (if still
used) or infections from organisms, such as staphylococcus, chlamydia
trachomatis, or gonococcus. Tear formation does not usually begin until age 2 to 3
months.
o Jaundice may be seen in sclera because of physiologic jaundice or, if severe,
blood group incompatibility.
o Pupils equal in size and should constrict equally in bright light.
o Infant can see and discriminate patterns; limited by imperfect oculomotor
coordination and inability to accommodate for varying distances.
o Red reflex red-orange color seen when light from an ophthalmoscope is reflected
from the retina. No red reflex indicates cataracts.
o Brushfield's spots white or yellow pinpoint areas on iris that may indicate trisomy
21 or even a normal variant.
o Abnormal placement of eyes or small eye openings can signify a syndrome or
chromosomal anomaly.
o Strabismus (cross-eyed) appearance that is common; nystagmus (constant, rapid,
involuntary movement of the eye) is also common and disappears by age 4
months.
Nose examine the following:
o Patency necessary because infants breathe through the nose, not the mouth.
o Nasal flaring abnormal and may indicate respiratory distress. Check for
appropriate size and shape of the nose; should be placed vertically midline in face.
 o Discharge stuffiness is normal unless chronic nasal discharge is present; may be
caused by possible infection.
o Sense of smell infants will turn toward familiar odors and away from noxious
odors.
o Septum should be midline; low nasal bridge with broad base may be associated
with Down syndrome.
o Periodic sneezing is common.
Ears examine the following:
o Formation large, flabby ears that slant forward may indicate abnormalities of the
kidney or other parts of the urinary tract.
o Position in relation to the eye helix (top of ear) on the same plane as eye; low-set
ears may ind icate chromosomal or renal abnormalities.
o Cartilagefull-term infant has sufficient cartilage to make the ear feel firm.
o Hearing auditory canals may be congested for a day or two after birth; the infant
should hear well in a few days.
o Observe for skin tags; preauricular sinus located in front of the ear may be normal
or may be associated with genetic disorders.
Mouth examine the following:
o Size small mouth found in trisomy 18 and 21; corners of mouth turn down (fish
mouth) in fetal alcohol syndrome. Mucous membranes should be pink.
o Palate examine hard and soft palate for closure.
o Size of tongue in relation to mouth normally does not extend much past the
margin of gums. Excessively large tongue seen in congenital anomalies, such as
cretinism and trisomy 21.
o Teeth predeciduous teeth are found on rare occasions; if they interfere with
feeding, they may be removed.
o Epstein's pearls small white nodules found on sides of hard palate (commonly
mistaken for teeth); regress in a few weeks.
o Frenulum linguae thin ridge of tissue running from base of tongue along
undersurface to tip of tongue, formerly believed to cause tongue-tie; no treatment
necessary. True congenital ankyloglossia (tongue-tie) is rare.
o Sucking blisters (labial taberales) thickened areas on midline of upper lip that may
be filled with fluid or callous; no treatment necessary.
o Infections thrush, caused by Candida albicans, may appear as white patches on
tongue and/or insides of cheeks that do not wash away with fluids; treated with
nystatin suspension.

Neck:
Examine the following:

Mobility infant can move head from side to side; palpate for lymph nodes; palpate
clavicle for fractures, especially after a difficult delivery.
Torticollis appears as a spasmodic, one-sided contraction of neck muscles; generally from
hematoma of sternocleidomastoid muscle; usually no treatment required.
Excessive skin folds may be associated with congenital abnormalities such as trisomy 21.
Stiffness and hyperextension may be caused by trauma or infection.
 Clavicle for intactness.
Observe for masses such as cystic hygroma soft and usually seen laterally or over the
clavicle.

Chest:

Circumference and symmetry average circumference is 12 to 13 inches (30 to 33 cm),

approximately inch (2 cm) smaller than head circumference.
Breast:
o Engorgement may occur at day 3 because of withdrawal of maternal hormones,
especially estrogen; no treatment required. Regresses in 2 weeks.
o Nipples and areolae less formed and pronounced in preterm infants.

Respiratory System

Rate normally between 40 to 60 breaths/minute; influenced by sleep-wake status, when

last fed, drugs taken by mother, and room temperature.
Rhythm respirations may be shallow with irregular rhythm.
o Respiratory movements are symmetric and mainly diaphragmatic because of
weak thoracic muscles. For example, the lower thorax pulls in and the abdomen
bulges with each respiration.
o Periodic breathing resumption of respiration after 5- to 15-second period without
respiration; decreases with time; more common in preterm infants. Substernal
retractions if accompanied by gasps or stridor is indicative of upper airway
obstruction.
o Observe for abnormal respiratory signs.
Breath sounds determined by auscultation.
o Bronchial sounds are heard over most of the chest.
o Rales may be heard immediately after birth.
o Expiratory grunting is indicative of respiratory distress syndrome (RDS).

Cardiovascular System

Rate normal between 110 to 160 bpm (80 to 110 normal with deep sleep); influenced by
behavioral state, environmental temperature, medication; take apical count for 1 minute.
Rhythm common to find periods of deceleration followed by periods of acceleration.
Heart sounds second sound higher in pitch and sharper than first; third and fourth sounds
rarely heard; murmurs common, majority are transitory and benign.
Pulses examine equality and strength of brachial, radial, pedal, and femoral pulses; lack
of femoral pulses indicative of inadequate aortic blood flow.
Cyanosis examine for cyanosis. Acrocyanosis of distal extremities is common; record
location of any cyanosis, color changes with time, and when crying.
Blood pressure neonates who weigh more than 3 kg have systolic blood pressure between
60 to 80 mm Hg; diastolic, between 35 and 55 mm Hg. Blood pressure is usually higher
in the lower extremities than in the upper extremities. Blood pressure assessment may not
be conducted routinely on healthy neonates. Measurement of blood pressure is essential
 for infants who show signs of distress, are premature, or are suspected of having a cardiac
anomaly.

Abdomen:

Shape cylindrical, protrudes slightly, moves synchronously with chest in respiration.

Distention may be caused by bowel obstruction, organ enlargement, or infection.
Palpate abdomen for masses; gap between rectus muscles is common; palpate liver and
spleen.
o Liver has decreased ability to conjugate bilirubin (rationale for physiologic
jaundice).
o Liver has decreased production of prothrombin and factors that depend on vitamin
K for synthesis (rationale for neonate's predisposition to hemorrhage).
Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds occur
an hour after delivery.
Kidneys palpate kidneys for size and shape.
o Infant has decreased ability of kidney to concentrate urine, excrete a solute load,
maintain water and electrolyte balance.
o Urine may contain uric acid crystals, which appear on diaper as reddish blotches;
uric acid crystals may yield false-positive result when the infant's urine is tested
for protein.

Umbilical cord
o Normally contains two arteries, one vein; single artery sometimes associated with
renal and other congenital abnormalities.
o Signs of infection around insertion into abdominal wall-redness, discharge.
o Meconium staining associated with intrauterine compromise or postmaturity.
o By 24 hours, becomes yellowish brown; dries and falls off in approximately 10 to
14 days.
o Umbilical hernia defect in abdominal wall.

Genitalia:

o Female:

Labia majora cover labia minora and clitoris in full-term female infants.
Hymenal tag (tissue) may protrude from vagina regresses within several
weeks.
Vaginal discharge white mucous discharge common; pink-tinged mucous
discharge (pseudomenstruation) may be present because of the drop in
maternal hormones; no treatment necessary.
o Male
Full-term testes in scrotal sac; scrotal sac appears markedly wrinkled due
to rugae.
 Edema may be present in scrotal sac if the infant was born in breech
presentation; a frank collection of fluid in the scrotal sac is a hydrocele
regresses in approximately a month.
Examine glans penis for urethral opening normally central; opening
ventral (hypospadias); opening dorsally (epispadias); abnormally adherent
foreskin (phimosis).
o Check for patent anus infant should stool within 24 hours after delivery. If passed
meconium in utero, patent anus has been established.

Back:

Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus; also
for tufts of hair or skin disruptions that would indicate possible spina bifida.
Examine anal area for anal opening, response of anal sphincter, fissures.

Musculoskeletal System:

Examine extremities for fractures, paralysis, range of motion, irregular position.

Examine fingers and toes for number and separation: extra digits, polydactyly; fused
digits, syndactyly.
Examine hips for dislocation with the infant in supine position, flex knees and abduct
hips to side and down to table surface; clicking sound indicates dislocation (Ortolani's
sign).
Asymmetrical gluteal folds also indicate congenital hip dislocation.
Examine feet for structural and positional deformities, ie, club foot (talipes equinovarus)
or metatarsus adductus (inward turning of the foot).

Neurologic System:

Neurologic mechanisms are immature anatomically and physiologically; as a result,

uncoordinated movements, labile temperature regulation, and lack of control over
musculature are characteristic of the infant.
Examine muscle tone, head control, and reflexes.
Two types of reflexes are present in the neonate:
o Protective in nature (blink, cough, sneeze, gag) remain throughout life.
o Primitive in nature (rooting/sucking, moro, startle, tonic neck, stepping, and
palmar/plantar grasp) either disappear within months or become highly developed
and voluntary (sucking and grasping).