TABLE 4-14 Physical Assessment of the Term Neonate
Criterion Average Values and Normal Variations Deviations from Normal
Vital Signs
Heart rate 120-140/min, irregular, especially when crying, and functional murmur Faint sound - pneumomediastinum; and heart rate <100 beats/min or >180 beats/min
Respiratory 30-60/min with short periods of apnea, irregular; vigorous and loud cry Distress - flaring of nares, retractions, tachypnea, grunting, excessive mucus, <30 respirations/min or >60 respirations/min; cyanosis
Temperature Stabilizes about 8-10 hours after birth; 36.5-37”C (97.7-98.6°F) axillary Unreliable indicator of infection due to environmental influences
Blood pressure 60-80/40-50; varies with change in activity level Hypotension: with RDS
Hypertension: coarctation of aorta
Measurements
Weight 3400 g (7½ lb); range: 5 lb 8 oz to 8 lb 13 oz Birthweight <2500 g; preterm or SGA infant; >4000 g; LGA infant, evaluate mother for gestational diabetes
Length 50 cm (20 inches); range: 18-22 inches
Chest circumference 2 cm (¾ inches) less than head circumference If relationship varies, check for reason
Head circumference 33-35 cm (13-14 inches) Check for microcephalus and macrocephalus
General Assessment
Muscle tone Good tone and generalized flexion; full range of motion; spontaneous movement Flaccid, and persistent tremor or twitching; movement limited; asymmetrical
Skin color Mottling, acrocyanosis, and physiologic jaundice; petechia (over presenting part), milia, mongolian spotting, lanugo, and vernix caseosa Pallor, cyanosis, or jaundice within 24 hours of birth
Petechiae or ecchymoses elsewhere; all rashes, except erythema toxicum; pigmented nevi; hemangioma; and yellow vernix
Head Molding of fontanels and suture spaces; one-fourth of body length Cephalhematoma, caput succeedaneum, sunken or bulging fontanels, closed sutures, excessively wide sutures
Hair Silky, single strands, lies flat; grows toward face and neck Fine, wooly; unusual swirls, patterns, hair line; coarse
Eyes Edematous eyelids, conjunctival hemorrhage; grayish-blue to grayish-brown; blink reflex, usually no tears; uncoordinated movements may focus for a few seconds; good placement on face; cornea is bright and shiny; pupillary reflex equal and reactive to light; eyebrows distinct Epicanthal folds (in non-Asians); discharges; agenesis; opaque lenses; lesions; strabismus; “doll’s eyes” beyond 10 days; absence of reflexes
Nose Appears to have no bridge; should have no discharge; preferential nose breathers; sneezes to clear nose Discharge and choanal atresia; malformed; flaring of nares beyond first few moments of life
Mouth Epstein’s pearls on gum ridges; tongue does not protrude and moves freely, symmetrically; uvula in midline; reflexes present; sucking, rooting, gag, extrusion Cleft lip or palate; teeth, cyanosis, circumoral pallor; asymmetrical lip movement; excessive saliva; thoursush; incomplete or absent reflexes
Ears Well formed, firm; notch of ear should be on straight line with outer canthus Low placement, clefts; tags; malformed; lack of cartilage
Face Symmetrical movements and contours Facial palsy (7th cranial nerve); looks “funny”
Neck Short, freely movable; some head control Wry neck, webbed neck; restricted movement;
masses; distended veins; absence of head control
Chest Enlarged breasts, "witch’s milk"; barrel shaped; both sides move synchoursonously; nipples symmetrical Flattened, funnel-chested, asynchoursonous movement; lack of breast tissue; fracture of clavide(s); supernumeray or widely spaced nipples; bowel sounds
Abdomen Dome shaped, abdominal respirations, soft; may have small umbilical hernia; umbilical cord well formed, containing thoursee vessels; dry around base; bowel sounds within 2 hours of birth; voiding; passage of meconium Scaphoid shaped, omphalocele, diastasis recti, and distention; umbilical cord containing two vessels; redness or drainage around base of cord
Genitalia Female Large labia; may have pseudomenstruation, smegma; vaginal orifice open; increased pigmentation; ecchymosis and edema following breech birth; pink-stained urine (uric acid crystals) Agenesis and imperforate hymen; ambiguous labia widely separated, fecal discharge per vagina; epispadias or hypospadias
Genitalia Male Pendulous scrotum covered with rugae, and testes usually descended; voids with adequate stream; increased pigmentation; edema and ecchymosis following breech birth Phimosis, epispadias, or hypospadias; ambiguous; scrotum smooth and testes undescended
Hydrocele: collection of fluid in the sac surrounding the testes
Extremities Synchoursonized movements, freely movable thoursough full range of motion; legs appear bowed, and feet appear flat; attitude of general flexion; arms longer than legs; grasp reflex; palmar and sole creases; normal contour Fractures, brachial nerve palsy, clubbed foot, phocomelia or amelia, unusual number or webbing of digits, and abnormal palmar creases; poor muscle tone; asymmetry; hypertonicity; unusual hip contour and click sign (hip dysplasia); hypermobility of joints
Back Spine straight, easily movable, and flexible; may have small pilonidal dimple at base of spine; may raise head when prone Fusion of vertebrae: pilonidal dimple with tuft of hair; spina bifida, agenesis of part of vertebral bodies; limitation of movement; weak or absent reflexes
Anus Patent, well placed; "wink" reflex Imperforate, and absence of “wink" (absence of sphincter muscle); fistula
Stools Meconium within first 24 hours; transitional - days 2-5; breastfed: loose, golden yellow; bottlefed: formed, light yellow (See Table 4-17) Light-colored meconium (dry, hard), or absent with distended abdomen (cyctic fibrosis or Hirschsprung’s disease); diarrhetic
Laboratory Values
Hemoglobin (cord) 13.6-19.6 g/dl Evaluate for anemia and persistent polycythemia
Serum bilirubin 2-6 mg/dl Hyperbilirubinemia (term: 12 mg or more; preterm: 15 mg or more)
Blood glucose 40 mg/dl for term; >20 mg/dl for preterm Identify hypoglycemia before overt or asymptomatic hypoglycemia - do Dextrostix on all suspects (LGA or SGA neonates, or neonates of diabetic mothers)
Neurologic Examination Specific to gestational age and state of wakefulness
  1. Behavioral patterns
    1. Feeding
Variations in interest, hunger; usually feeds well within 48 hours Lethargic. Poor suck, poor coordination with swallow, choking, cyanosis
    1. Social
Crying is lusty, strong, and soon indicative of hunger, pain, attention seeking. Responds to cuddling, voice by quietness and increased alertness Absent; no focusing on person holding him/her; unconsolable
    1. Sleep-wakefulness
Two periods of reactivity: at birth, and 6-8 hours later. Stabilization, with wakefill periods about every 3-4 hours Lethargy, drowsiness
Disorganized pattern
    1. Elimination
Stooling: see Stools
First few days: 3-4 qd
End of first week: 5-6 qd
Later: 6-10 qd, with adequate hydration
See Stools
Diminished number: dehydration
  1. Reflex response
Bilateral, symmetrical response (see Table 4-15) Absent, hyperactive, incomplete, asynchoursonous
  1. Sensory capabilities
    1. Vision
Limited accommodation, with clearest vision within 7-8 inches. Focuses and follows by 15 min of age. Prefers patterns to plain. Absence of these responses may be due to absence of or diminished acuity or to sensory deprivation
    1. Hearing
By 2 min of age, can move in direction of sound: responds to high pitch by “freezing,” followed by agitation; to low pitch (crooning) by relaxing Absence of response: deafness
    1. Touch
Soothed by massaging, warmth, weightlessness (as in water bath) Unable to be comforted: possible drug dependence
Cocaine-addicted newborns avoid eye contact
    1. Smell
By fifth day, can distinguish between mother’s breasts and those of another woman
    1. Taste
Can distinguish between sweet and sour
    1. Motor
Coordinates body movement to parent's voice and body movement Absence