Chapter 20: Assessment of the Normal Newborn

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Hello and welcome back to the Deep Dive.

Today we're shifting gears quite a bit.

We are doing something a little bit different, something really special for all of you nursing students out there, the learners, or honestly anyone who just wants to understand the absolute biological miracle that is a newborn baby.

That's right.

Usually we take a pretty broad, sometimes abstract look at a topic, but today we are going into full -on tutorial mode.

We are laser focused on a very specific,

very critical text.

We are diving into chapter 20, assessment of the normal newborn from Maternal Newborn and Women's Health Nursing, the seventh edition.

Yeah, so if you are prepping for an exam right now, getting ready for your very first clinical rotation in the nursery, which let's be honest can be absolutely terrifying, or you just want to know exactly what is happening in those first few hours of life, this Deep Dive is for you.

We are going to walk through the admission assessment in the exact order of the text.

And we aren't just skimming the surface here.

We are going to unpack the why behind every single check, every reflex, every measurement.

We really want you to feel like you are right there at the bedside with the infant.

Exactly.

Think of this as a one -on -one tutoring, no stress,

just the facts, but with enough context that you actually remember them when you are standing in front of your instructor.

So set the scene for us.

The baby is born.

What is the overarching mission here?

The mission is adaptation.

You have to realize this fetus has been floating in a warm, dark, fluid -filled environment for months where literally everything was done for them.

Oxygen, nutrition, waste removal, all of it handled completely by the placenta, and then suddenly they are out.

Right.

It's cold, it's bright.

It's cold, it's extremely bright, and for the very first time they have to breathe air, pump their own blood to the lungs, and regulate their own body temperature.

It is a massive physiological shock.

It really is.

So the nurse's primary role in that initial admission assessment is to determine, is this transition happening safely?

Is the baby adapting to Extruder -in -Life, or are they struggling?

Okay, so let's get into the early focused assessments section.

The baby is out.

The delivery room is chaotic.

What is the absolute priority?

Cardio -respiratory status.

Always, always cardio -respiratory status.

Airway, breathing, circulation.

If those aren't working, literally nothing else matters yet.

We are looking at their cardio -respiratory status, their muscle tone, thermoregulation, which is keeping them warm, and quickly checking for any major obvious anomalies.

And before we even lay hand on the baby, there is a major safety check mentioned right at the start of the text.

It seems simple, but it is bolded for a reason.

Gloves.

Yes, gloves.

It sounds incredibly basic, but it's so critical.

You have to remember, after the baby is dried off, their skin is still contaminated with maternal blood and amniotic fluid.

You must wear gloves until the infant is fully bathed and all that blood is removed.

It's a fundamental standard precaution to protect the nurse from bloodborne pathogens.

Safety first, always.

Got it.

Now, you mentioned cardio -respiratory status as the priority.

I imagine breathing is priority number one in that category.

It is.

And interestingly enough, the respiratory assessment actually starts with history -taking.

Before you even look at the baby, you need to know what happened during labor.

For example, if the mother received narcotic analgesics, things like Demerol or statylate in labor,

that fetal central nervous system might be depressed when they come out.

Which means the baby might not have the drive to breathe as readily, right?

Exactly.

Or let's say the baby is preterm.

They might not have enough surfactant, meaning their alveoli, those tiny air sacs in the lungs,

won't be able to stay open.

So you go into the assessment already knowing the potential risks.

Okay, so let's look at the baby now.

We are checking the airway.

The text talks quite a bit about fluid in the lungs.

Right, because during birth, some of that fetal lung fluid is forced out mechanically.

If it's a vaginal birth, the baby gets squeezed very tightly as they move through the birth canal.

That intense pressure on the chest actually forces a lot of the fetal lung fluid right out of the mouth and nose.

It's often called the thoracic squeeze.

But a c -section baby doesn't get that squeeze.

Precisely.

A baby born by cesarean section entirely misses that mechanical squeeze, so they tend to have quite a bit more fluid left in their lungs.

You might hear coarse breath sounds or crackles for a bit longer because they literally just have to absorb that extra fluid into their bloodstream.

It's usually transient, but you absolutely expect it.

That makes total sense.

Let's get to the numbers.

You need to know the normal respiratory rate for an exam.

Lay it on me.

Normal is 30 to 60 breaths per minute.

The average usually sits somewhere between 40 and 49.

30 to 60.

I mean, that sounds incredibly fast compared to an adult who is usually sitting at around 12 to 20.

It is much faster.

And it can be even faster than that immediately after birth or when the baby is crying.

But here's the trick to assessing it.

The text emphasizes this.

Newborn breathing is irregular.

It's shallow.

It can be incredibly hard to count just by looking.

So you can't just count for 15 seconds and multiply by four like we do with adults in medsurg.

Absolutely not.

The text is very specific on this procedure.

You must count for a full minute.

You need to observe carefully,

maybe lightly place a hand on the abdomen because newborns are belly breathers.

You have to be patient and watch the rise and fall for 60 full seconds.

Now you mentioned it's irregular, but when does irregular become abnormal?

That is a great question.

We actually expect something called periodic breathing.

This is where the baby stops breathing entirely for maybe five to 10 seconds, but then picks right back up with rapid respirations for the next 10 to 15 seconds.

That is considered normal, especially in preterm infants.

OK, so a short five second pause is totally OK.

Yes, but apnea is entirely different.

Apnea is defined as a pause in breathing lasting 20 seconds or more.

Or, and this is important, if the pause is shorter than 20 seconds, but it's accompanied by cyanosis, meaning turning blue or pallor, bradycardia, or decreased muscle tone.

Any of that means the apnea is abnormal.

It requires immediate medical intervention.

That is a crucial distinction for you to note.

Periodic breathing is a normal pause.

Apnea is a problem.

And what about the sounds?

If I'm listening with my stethoscope, what do I want to hear?

You obviously want to hear clear breath sounds throughout the fields, but in that first hour or two of life, you might hear some crackles.

Like we mentioned earlier, that's just the remaining fetal lung fluid being absorbed.

It's usually perfectly fine.

However, if you hear persistent wheezes, stridor,

or if those initial crackles do not go away, you must report it.

OK, let's talk about the red flags, the absolute must -knows for respiratory distress.

If I'm a student doing my assessment, what are the visual signs I'm hunting for?

First is tachypnea.

That's a respiratory rate over 60 breaths per minute, consistently.

Not just when the baby is crying or agitated, but a consistently rapid baseline rate.

OK, tachypnea.

Second is retractions.

This is when the soft tissue around the bones of the chest gets drawn inward during inspiration.

The baby is working so incredibly hard to pull air into the lungs that you actually see the skin suck in.

You can see it right under the breastbone, which is sub -sternal, or between the ribs, intercostal, or even above the That sounds really alarming to look at.

It is.

It clearly shows they are struggling against resistance in the airway.

The third sign is flaring of the nares.

Like the nostrils getting physically whiter.

Yes, exactly.

It's a compensatory reflex.

By whiting the nostrils, the baby is instinctively trying to decrease airway resistance to pull in more oxygen.

If you see intermittent flaring in the first hour right after birth, you keep a close eye on it.

If tachypnea, retractions, flaring, what about skin color?

Cyanosis is a huge indicator, but we have to be very careful here.

You need to differentiate central cyanosis from acrosyanosis.

Break that down for us because that trips up a lot of people.

Acrosyanosis involves only the extremities.

So the hands and feet are blue, but the rest of the body is pink.

This is actually completely normal in the first day of life, or if the baby just gets a little cold.

It's simply due to poor sluggish perfusion to the peripheral blood vessels.

So blue hands are generally okay?

Generally, yes.

But central cyanosis involves the lips, the tongue, the mucous membranes, and the central trunk of the body.

That indicates true hypoxia.

It means not enough oxygen is reaching the vital organs and the brain.

That requires immediate emergency attention.

And the text mentioned a specific blanch test for this, right?

Right.

Sometimes a baby's face gets bruised from a difficult birth and it looks purple or blue.

If you apply pressure to a bruise, it stays blue.

But if you apply pressure to a cyanotic area of skin, it will blanch, meaning it turns white, and then it will turn blue again when you release the pressure.

That is a pro tip right there for clinicals.

Okay, are there any other sounds of distress we should listen for without the stethoscope?

Grunting.

This is a very specific noise made on expiration.

It sounds like a little low -pitched sound every time they breathe out.

Why do they do that physiologically?

They are actively exhaling against closed focal cords.

Doing this drastically increases the pressure inside the alveoli to force them to stay open.

It's basically the baby giving themselves continuous positive airway pressure, or PEEP.

It is a sign of severe, significant respiratory distress.

Wow.

The human body is just amazing.

Even when it's in severe distress, it has these built -in mechanisms to try to fix itself.

It really is.

One more major visual sign is seesaw respirations.

Normally, when a baby breathes in, the chest and the abdomen rise together synchronously.

In severe distress, the chest falls inward when the abdomen rises outward.

It's an alternating paradoxical movement, and it is a very bad sign.

Okay, noted.

Before we move completely off breathing, there is a specific anatomical condition mentioned called coenal atresia.

What exactly is that?

It's a congenital blockage or narrowing of the navel passages by bone or tissue.

This is a critical emergency, because newborns are preferential nose breathers for the first four to six weeks of life.

They literally do not know how to breathe through their mouths unless they are actively crying.

Oh, wow.

So if their nose is blocked at birth, they can suffocate.

Exactly.

To assess for this, you close the infant's mouth gently and occlude one nostril at a time.

You listen and observe their color.

If the baby is perfectly pink when crying because their mouth is open, but they turn blue the second they quiet down and close their mouth, you absolutely have to suspect a nasal blockage.

Got it.

Pink when crying, blue when quiet.

That's a great memory trick.

Okay, moving over to the cardiovascular system, we're listening to the heart.

What are we listening for?

You are listening to the rate and the rhythm.

The normal heart rate for a newborn is 120 to 160 beats per minute.

Again, incredibly fast compared to us.

Yes.

If they're deep in sleep, it might drop down to 100.

If they're screaming and crying, you can shoot all the way up to 180.

But 120 to 160 is your baseline normal.

You listen right at the apex, which is the point of maximum impulse, usually at the third or fourth intercostal space.

And what about murmurs?

I feel like I hear about newborn babies having murmurs all the time.

You do hear about a lot because about 10 % of all newborns have them.

It's usually just due to an incomplete transition.

The ductus arteriosus, which is a fetal blood vessel, hasn't fully closed yet.

Most of these murmurs are entirely temporary and benign, but you must document them and monitor them closely because they can also be early signs of congenital cardiac defects.

Now, there's a very specific check regarding pulses that seems really important for catching those heart defects, the brachial versus femoral pulse check.

Yes, this is a critical comparative assessment.

You physically palpate the brachial pulse up in the arm and the femoral pulse down in the groin at the exact same time.

They should be completely equal in strength and bounding.

And if they aren't equal?

If the femoral pulses in the legs are noticeably weaker than the brachial pulses in the arms, you have to suspect coerctation of the aorta.

That's a congenital narrowing of the descending aorta that severely impedes blood flow to the lower half of the body.

So strong pulses in the arms but weak pulses in the legs equals a major heart problem.

Precisely.

And if you suspect based on the pulses, you would then take their blood pressure.

Normally, taking blood pressure isn't a routine part of a healthy newborn assessment, but if there are any cardiac signs, you do it on all four extremities.

And interestingly enough, the blood pressure in the legs should actually be slightly higher than in the arms in a normal newborn.

If the leg pressure is lower, again, that points straight to coerctation.

And just to wrap up the cardiovascular section, what about capillary refill?

It's the same general concept as adults, but you perform it over the sternum.

You depress the skin over the chest bone, it should blanch white, and the pink color should return in less than three to four seconds.

Okay, breathing and heart check.

Let's move on to temperature.

Thermoregulation.

This is huge.

Babies lose heat incredibly fast because of their large surface area to mass ratio.

You assess their temperature every 30 minutes after birth until they have been completely stable for two solid hours.

And where exactly are we taking this temperature?

Axillary.

Deep under the arm.

That is the universally preferred safe method.

The normal axillary range is 36 .5 to 37 .5 degrees Celsius.

If you're using Fahrenheit, that translates to 97 .7 to 99 .5.

Why not rectal?

Because I know that used to be the gold standard for exact core temperature in babies.

We avoid it now unless it is absolutely medically necessary.

There is a very real risk of perforating the fragile rectal mucosa.

The text points out a specific anatomical reason for this.

The newborn rectum actually turns at a sharp right angle about three centimeters in.

Ouch.

Yeah, that sounds dangerous.

Exactly.

If you force a stiff thermometer past that turn, you can cause serious life -threatening damage.

Also, taking a rectal temp can stimulate the vagus nerve and drop their heart rate.

So just stick to the axillary method.

Good advice.

Okay, let's move to the general assessment.

We are looking at the baby structurally from head to toe.

Let's start with the head.

It's, well, it's big.

It is disproportionately large.

The newborn head is about one -fourth of their total body surface area.

It's huge compared to the rest of the body.

And because of that intense physical journey through the birth canal, it might be pretty misshapen.

We call that molding.

Ah, the classic cone head.

Right.

The cranial bones aren't fused yet, so they actually override each other to fit through the

over the occipital or frontal bones.

It looks alarming to parents, but it usually resolves on its own in a few days to a week.

And part of checking the skull means feeling the soft spots, the fontanels.

Correct.

You have two main ones to assess.

The anterior font hell is diamond -shaped.

It's located right where the frontal and parietal bones meet on top.

That one stays open a long time.

It closes by about 18 months of age.

And what should it feel like when I touch it?

It should feel soft and flat.

If it's bulging outward when the baby is calm, not crying, because crying makes it bulge naturally.

But if it's bulging while calm, that could mean increased intracranial pressure.

On the flip side, if it's depressed or visibly sunken in, that is a classic sign of dehydration.

And the posterior fontanel.

That one is triangular and much smaller.

It's toward the back of the head.

It closes much sooner, usually by two months of age.

Now, here is a classic nursing school exam topic that always trips people up.

The difference between caput sixidanium and cephalohumatoma.

They are both bumps or swelling on the head, but they are very, very different clinically.

This is a huge key examination topic.

Let's break it down clearly.

Caput sixidanium is generalized edema.

It's swelling of the soft tissue of the scalp.

It happens from the mechanical pressure of the head pushing against the cervix during labor, the absolute key identifier for caput.

It crosses the cranial suture line.

Okay, so it crosses the suture lines.

Yes.

Think of it like a cap sitting on the head.

Caput equals cap.

It's soft, it's squishy, and it resolves very quickly, usually in 12 to 48 hours without any treatment.

Okay, so caput means cap and it crosses.

What about cephalohumatoma?

Cephalohumatoma is entirely different.

It is actual bleeding happening between the periosteum, which is the tough membrane covering the bone, and the skull bone itself.

Because the bleeding is physically trapped underneath that periosteum layer, it stops exactly at the bone edges.

Therefore, it does not cross the suture lines.

So it's a very distinct firm lump confined strictly to one bone plate.

Exactly.

And because it's an actual collection of blood rather than just fluid edema, it takes much, much longer to resolve, sometimes months even.

And here's the big so what for your practice.

As that trapped blood eventually breaks down, the red blood cells release bilirubin.

So infants with cephalohumatoma are at a significantly higher risk for developing jaundice.

That is a brilliant connection to make for an exam.

Bleeding leads to bilirubin, which leads to jaundice.

Okay, moving down the body to the face, neck, and clavicles.

For the face, you are mostly checking for symmetry.

If the baby cries and one side of the mouth droops, you suspect facial nerve trauma from the delivery.

The neck itself is very short.

You want to check for abnormal webbing or large fat pads, which can indicate chromosomal anomalies like Turner syndrome or Down syndrome.

But the big assessment here is the clavicles.

Why are we so worried about collarbones in a newborn?

Fractures.

They are surprisingly common, especially in large infants, or if there was a shoulder dystocia, where the baby's shoulder gets stuck behind the mother's pubic bone during birth.

You need to carefully palpate both clavicles.

If you feel crepitus, which is a crunchy grating sensation or a distinct lump, or if the baby screams in pain when you touch that specific area, you suspect a fracture.

And how do you even treat a broken collarbone in a baby that small?

It's incredibly low tech.

Usually, you just immobilize the affected arm by pinning the sleeve of their shirt straight to the front of the shirt across their chest.

It heals remarkably quickly on its own.

Simple enough.

Alright, moving down to the abdomen, the umbilical cord.

You are looking closely at the cut end of the cord for three blood vessels.

Think of the acronym AVA.

Artery, vein, artery.

Two arteries, one vein.

What if there is only one artery and one vein?

A two vessel cord can sometimes just be an isolated, benign finding.

But it is very often associated with chromosomal abnormalities or congenital renal defects.

So if you see a two vessel cord, you'd want the provider to look a little closer at the which is the thick gelatinous cushioning stuff inside the cord, and check for any meconium staining on the cord itself.

If the cord is tinted, yellow -brown or green instead of white.

It means meconium, the baby's first stool, was released into the amniotic fluid before birth.

That almost always hints at some episode of fetal compromise or severe stress in utero.

Now let's look at the extremities.

The arms and legs.

You want to see active, spontaneous movement of all four limbs.

A healthy term infant should naturally rest in a flexed position.

Their arms and legs should be pulled in tight to their body, and they should actively resist you trying to extend them.

If they are lying flat, limp, or floppy, that indicates poor muscle tone and neurological depression.

We talked about the clavicle fracture earlier, but what about actual nerve injury in the arm?

You are looking for a brachial plexus injury, which is also called Herb's Palsy.

This happens if the bundle of nerves in the shoulder gets severely stretched or torn during a difficult birth.

The classic textbook sign is the affected arm hanging completely limp at their side, fully extended, with the forearm rotated inward and prone.

They call it the waiter's tip position.

Like a waiter subtly holding their hand out behind their back, asking for a tip.

Exactly.

You'll clearly see diminished or completely absent movement on that affected side when you test the moral reflex.

Let's shake the hands and feet.

We're counting digits, right?

Count every single one of them.

Polydactyly is having extra fingers or toes.

Syndactyly is having webbed digits fused together.

And you also need to look closely at the palms of the hands.

Usually we all have two distinct transverse creases across our palms.

If you look at the baby and see a single line running straight across the entire palm, that's called a semi -increase.

It can be strongly associated with down syndrome, though it's worth noting some perfectly normal, healthy infants have it too.

And the feet.

Club foot is something we specifically look for.

The medical term is talipase equinevarus.

You need to carefully distinguish between a positional club foot and a true structural club foot.

If the foot looks turned sharply inward, but you can gently manipulate it with your hands back to a normal straight midline position, it's just positional.

It happened because they were squished in the womb for nine months.

True club foot is rigid.

The bones are actually deformed, and the foot cannot be physically moved to the midline.

Okay.

Now moving to the hips.

Developmental dysplasia of the hip, or DDH.

This is a major check.

It is.

Visually, before you even touch them, you look at the back of their legs for asymmetry.

Are the gluteal creases,

the butt cheeks, and the thigh folds uneven?

Does one leg look physically shorter than the other when they're lying flat?

And then there are the physical maneuvers.

The names of these always trip students up.

Barlow and Ortolani.

Let's simplify them so you never forget.

These maneuvers are usually performed by an advanced provider like a doctor or midwife.

But as a nurse, you absolutely need to know what they are and what they mean.

For the Barlow test, you adduct the hips, meaning you bring the knees together toward the midline, and you push backward toward the exam table.

You are feeling to see if the head of the femur easily slips completely out of the hip socket.

Okay.

Barlow is bringing them together and pushing back to see if it pops out.

Right.

Then for the Ortolani test, you do the opposite.

You abduct the thighs, moving the knees far apart outward, and you lift forward.

You are checking to see if a hip that is already dislocated can slip back into the socket.

And what exactly are you feeling for in your hands when you do this?

You are feeling for a distinct clunk,

not a soft click.

Hip clicks are incredibly common in newborns, and it's usually just benign ligament noise.

A true clunk is the physical heavy sensation of the femoral head forcibly moving out of or back into the acetabulum.

That clunk definitively indicates hip dysplasia.

You flip the baby over and visually inspect and physically palpate the entire vertebral column.

You are looking for any signs of synobifida, which is a neural tube defect.

An obvious severe defect would be a visible sac protruding right out of the back, which is a meningocella.

But spina bifida occulta is hidden beneath the skin.

To catch that, you look very closely at the base of the spine for a deep dimple, an indentation, or a strange tuft of hair right over the lower spine.

So a hairy patch on the lower back absolutely needs medical investigation.

Okay, let's talk measurement.

Parents always obsess over the weight and length.

They absolutely do.

Let's do weight first.

The normal range for a full -term newborn is 2 ,500 to 4 ,000 grams.

That translates to roughly 5 .5 to 8 .8 pounds.

And they almost always lose weight right away in the hospital, which really freaks parents out.

It totally panics them.

But we have to provide that education and reassure them.

The 10 % rule is key here.

It is entirely expected and normal for newborns to lose up to 10 % of their total birth weight in the first week of life.

This happens due to the excretion of meconium,

major extracellular fluid shifts as they adapt, and the fact that their initial intake of colostrum is very low in volume.

They should steadily regain that weight and be right back to their birth weight by day 14.

Length is measured from the very top of the head to the heel with the leg fully extended.

What about measuring the head circumference?

Head circumference normally ranges from 32 to 38 centimeters.

You measure it right above the eyebrows and the ears.

The chest circumference is typically 30 to 36 centimeters measured right across the nipple line.

The general rule of thumb you need to memorize.

The head should be about two to three centimeters larger than the chest.

And if those proportions are way off?

If the head is significantly more than three centimeters larger than the chest, you have to suspect hydrocephalus, which is fluid building up in the brain.

If the head is smaller than the chest, you suspect microcephaly, which means poor brain growth.

Okay, let's get into the neurologic system.

This is where we actually get to play with the baby a bit and test their reflexes.

The text has a really great detailed table on this.

Reflexes are vital because they immediately tell us if the central nervous system is intact and functioning.

Let's run through the big ones you will definitely be tested on.

First is the Moro reflex.

Everyone calls this the startle reflex.

You hold the baby's arms and gently let their head drop backward just slightly, maybe about 30 degrees.

The normal response is the baby should dramatically extend and abduct their arms, throw them wide open and form a distinct C shape with their index finger and thumb.

Then they slowly bring their arms back in like they're embracing themselves.

What does it mean if they only throw one arm out and the other stays still?

That's a huge red flag.

You immediately suspect that fractured clavicle or the brachial plexus nerve injury we talked about earlier.

The response must be fully symmetrical.

Next are the palmar and plantar grasps.

Very straightforward.

You press your finger into the palm of their hand or the base of the toes on the sole of their foot.

Their fingers or toes should immediately curl tightly around your finger.

The babinski reflex.

Now in adults, a positive babinski is a major sign of brain damage.

But in babies?

It is totally normal in babies.

You take your finger or the back of a pen and stroke the sole of the foot starting from the heel, moving up the lateral edge and curving across the ball of the foot.

The expected newborn response is the big toe dorsiflexes and the other toes fan or flare wide out.

This flaring is perfectly normal until they are about eight or nine months old.

If an adult's toes flare like that, it means severe central nervous system lesions.

But in a newborn, it just means their nervous system is brand new and immature.

That is such an important distinction.

Rooting and sucking are next.

Stroke the side of their cheek near the mouth.

They should instantly turn their head toward the stimulus and open their mouth.

That's rooting.

Put a gloved finger or a nipple in their mouth and they should suck strongly.

These are absolutely essential survival reflexes for feeding.

The tonic neck reflex.

I always thought this one was so interesting to look at.

It's often called the fencing position.

While the baby is lying flat on their back supine, you gently turn their head completely to one side.

The baby will instinctively extend the arm and leg on the side they are facing while simultaneously flexing the arm and leg on the opposite side.

They literally look exactly like a tiny fencer posing for a match.

If you hold the baby firmly upright supporting their chest and let their bare feet lightly touch a solid flat surface, they will reflexively lift their feet up and down one at a time, making a stepping or walking motion.

Moving on to sensory assessments.

We are looking at the eyes and ears.

For the ears, you really need to check their anacomical alignment.

You visually draw an imaginary horizontal line straight from the outer corner of the baby's eye, the outer canthus, straight back to the ear.

The very top of the ear pinna should be perfectly even with or slightly above that imaginary line.

Low -set ears are a classic feature associated with several chromosomal abnormalities, specifically Down syndrome or serious renal agenesis issues.

Why renal?

Why are the ears and the kidneys connected?

It all comes down to embryology.

The structural development of the ears and the structural development of the kidneys occur at the exact same time in utero.

So if an environmental or genetic factor disrupts the ear development, it highly likely disrupted the kidney development too.

Ear defects essentially act as a visible red flag for invisible kidney defects.

That is fascinating.

And what about their eyes?

Right after birth, you might see significant eyelid edema or subconjunctival hemorrhages, which are little red spots of blood in the white part of the eye.

That's just from the intense pressure of the birth canal.

It looks bad, but it resolves completely on its own.

Strabismus, which is a slight crossing or wandering of the eyes, is also totally normal and transient for the first three or four months because their eye muscle control is so poor.

But there are some eye signs that are definitely not normal.

Yes.

Watch carefully for the setting sun sign.

This is where the colored iris appears pushed downward, and you can clearly see a rim of white sclera above the iris.

That is a major neurological sign that strongly indicates hydrocephalus.

And what about cataracts?

Babies

congenital cataracts.

You check for this using an ophthalmoscope to find the red reflex.

When you shine the light into the pupil, you should see a bright red -orange reflection from the retina.

If instead you see a cloudy or opaque white area over the pupil, that's a cataract and is frequently caused by congenital rubella infection.

One last crucial neuro thing to discuss.

Tremors versus seizures.

Newborns can be incredibly shaky.

How does a nurse actually know if it's just a normal tremor or a life -threatening seizure?

It relies on a very simple physical test.

If the baby's arm or leg is trembling rapidly, you firmly hold that limb and flex it.

If it's just a tremor or benign jitteriness, the shaking will instantly stop when you hold it securely.

If it is a true neurological seizure, the rhythmic muscle movement will continue to pull and jerk against your hand even while you're holding it tightly.

That is a brilliant immediate safety check right there.

Tremors stop when held, seizures don't.

And if it is just tremors, what's usually causing that?

Very often, excessive jitteriness means hypoglycemia low blood sugar, or hypocalcemia low blood calcium,

which actually leads us perfectly right into the hepatic system, the liver functions.

We need to talk about blood sugar and jaundice.

Yes, hypoglycemia is a massive concern in the newborn nursery.

The newborn brain absolutely relies on a steady supply of glucose to function and survive.

Risk factors for low blood sugar include preterm infants, babies who are large for gestational age or LGA,

infants born to diabetic mothers, or babies suffering from cold stress.

What does a hypoglycemic baby actually look like during an assessment?

They look unwell.

They are notoriously jittery.

They have very poor floppy muscle tone.

They might be sweating, which is dipheresis,

or poor feeding.

Or, this is the scary part, they might be completely asymptomatic.

They might show no signs at all until their brain is starving.

That is exactly why we proactively screen the at -risk infants.

What's the magic number we are looking for in the glucometer?

The clinical target is generally a blood glucose above 40 -45 mg per deciliter.

If it drops lower than that, the first line of defense is usually to immediately feed them breast milk or formula.

If it stays stubbornly low despite feeding, they will need IV glucose.

And obtaining that blood sample involves a heel stick procedure?

You can't just take the lancet and poke anywhere on the foot, right?

No, absolutely not.

The text highlights procedure 20 .3 and it's very specific.

You must strictly use the lateral or medial aspects of the heel.

You heavily avoid the dead center of the heel.

If you mistakenly poke the center bottom of the heel, you run a very high risk of the needle hitting the calcaneus bone and causing

osteomyelitis, which is a severe deep bone infection.

You also have to avoid the major nerves and arteries running right through the middle of the foot.

Side of heel only.

Stay away from the center.

Got it.

Now the other big liver function issue,

bilirubin and jaundice.

Jaundice is the yellowing of the skin caused by an excess buildup of bilirubin as red blood cells break down.

It famously progresses in a cephalocautal direction, meaning it starts at the head and slowly spreads down to the toes.

To assess for it accurately, you blanch the skin firmly on the tip of the nose or over the sternum.

When you release your finger, if the blanched area looks distinctly yellow before the pink color returns, that infant has jaundice.

And there is a massive timing rule here that students absolutely must memorize for their exams.

The biggest rule in this chapter, jaundice appearing in the first 24 hours of life is period.

It is completely abnormal.

It usually points to massive rapid hemolysis like an RH or ABO blood incompatibility with the mother or a serious liver disease.

Physiologic jaundice, which is the normal expected kind due to an immature liver, only appears after the first 24 hours of life.

First 24 hours equals danger of pathologic.

After 24 hours equals normal.

Physiologic.

Just monitor it.

Correct.

That distinction will save a baby's life and definitely show up on your boards.

Let's rapidly hit the gastrointestinal and genitourinary systems.

In the mouth, you need to look for precocious teeth.

Some babies are actually born with teeth.

They usually don't have roots, so they are incredibly loose and pose a massive aspiration risk.

They might need to be pulled immediately.

Look for Epstein's pearls, which are tawny, hard white cysts on the gum lines or hard palate.

Those are completely normal and disappear.

Then look for thrush.

Thrush presents as thick white patches on the tongue and cheeks that look exactly like milk curds, but if you try to wipe them off with a swab, they don't budge and the tissue underneath bleeds.

That's a fungal yeast infection usually acquired passing through the birth canal.

Finally, explicitly check for clefts.

You have to actually insert a gloved finger and palpate the entire hard and soft palate.

You cannot always see a soft palate cleft hidden in the back of the throat just by looking.

The first feeding is actually considered a major nursing assessment, right?

Absolutely.

When that baby takes their very first feed, you are intensely watching for the neurological coordination of the suck, swallow, and breathe reflexes.

If the baby actively chokes, severely coughs, or turns cyanotic and blue during that first feed, you stop feeding them immediately.

It strongly suggests esophageal atresia, where the esophagus just ends in a blind pouch and doesn't connect to the stomach, or atrachiosophageal fistula, where food is going into the lungs.

What should the newborn abdomen look like?

It should be perfectly dome -shaped and softly protuberant.

If it is distinctly sunken or scaphoid, meaning it curves inward like a bowl, that is a huge emergency.

That could indicate a diaphragmatic hernia, where the intestines have actually pushed up through a hole in the diaphragm right into the chest cavity crushing the lungs.

You'd likely hear bowel sounds up in the chest if you listened.

What about stools?

The first school is called myconium.

It is dark black, tory, and incredibly thick and sticky.

It should ideally be passed within the first 12 to 48 hours.

One crucial abnormal sign to look for in later stools.

If you see a water ring on the diaper, which is a wide wet ring of fluid soaking into the diaper surrounding a small clump of solid stool that specifically indicates severe diarrhea and massive fluid loss, not a normal breast -fed stool, and urine, the first void must occur within the first 12 to 24 hours.

Honestly, it's sometimes missed right birth because it happens in the delivery fluids.

By day four of life, as feeding gets established, we absolutely expect to see at least six heavily wet diapers every single day, and parents will panic about this next one.

Don't freak out if you see brick dust.

It looks like dark pink or orange powder stains right in the wet diaper.

Parents always think they are peeing pure blood, but it's really just concentrated uric acid crystals.

It's completely normal in the first few days of life while the kidneys are flushing things out.

That is so good to know for patient education.

And what about assessing the genitalia?

For females, prominent edema of the labia majorae and menorah is expected and normal.

You might also clearly see a thick milky white vaginal discharge or even a tiny streak of actual blood in the diaper.

That blood is called pseudo menstruation.

It is entirely caused by the sudden withdrawal of high maternal estrogen levels after birth.

Totally normal.

Just explain it to the parents.

For males,

carefully check that both tests are fully descended down into the scrotal sac.

Look closely for deep rugae, which are deep wrinkles on the skin of the scrotum.

That heavily indicates full gestational maturity.

And most importantly, check the exact location of the urethral opening, the meatus.

It should be right dead center of the tip of the glans penis.

If the opening is located underneath the penis on the ventral side, that's hypospadias.

Or if it's on the top dorsal side, that's epespadias.

And there's a massive rule for the nurse if you spot hypospadias or epispadias.

Yes, do not under any circumstances allow the infant to be circumcised.

The pediatric urologist will almost certainly need that intact foreskin tissue later to surgically reconstruct the urethra.

That is a critical do not do rule.

Okay, let's look at the skin, the integumentary system.

Newborns have so many weird rashes and color changes.

They really do.

Let's run through the most common ones you'll see.

First, the harlequin sign.

There's a stark line down the middle of the body and one side is deep red while the opposite side is entirely pale.

It looks bizarre, but it's just a harmless temporary vasomotor instability thing.

Modeling.

This is a lacy, web -like, red and blue pattern on the skin.

It almost always means that the baby is experiencing cold stress.

Vernix casiosa.

That's the thick, white, cream cheese -like protective coating on the skin.

Preterm babies are covered in it.

Postterm babies usually have none left at all.

Lanugo.

That's the very fine downy hair on the back and shoulders.

Again, abundant in preterms, but largely thins out and disappears by full term.

And there are quite a few specific bumps and rashes to document.

Melia are very common.

They are tiny, hard, white, sebaceous cysts, usually clustered on the nose, chin or forehead.

Educate the parents.

Do not try to pop them like pimples.

They will naturally go away in a few weeks.

Erythematoxicum.

This is famously called newborn rash or fleabite rash.

It presents as irregular red blotches with a distinct tiny, white or yellow center.

It moves around the body and is completely 100 % benign.

Birthmarks are a huge area for accurate documentation, right?

If you don't document it on admission, someone might think it's abuse later.

Yes, exactly.

Mongolian spots.

These are large, flat, dark, blue or gray macular patches, usually located over the sacrum or buttocks.

They are extremely common in infants of Asian, African or Hispanic descent.

You absolutely must document their exact size and location immediately upon admission, so they aren't mistakenly reported as severe bruising from child abuse later on.

Stork bites, medically known as navus simplex.

These are flat, irregular pink or red spots, usually on the eyelids, between the eyes or on the nape of the neck.

They blanch completely white when pressed and usually fade away by age 2.

Port wine stain or navus flamaeus.

This is a flat, dark, purple or red lesion that does not blanch when pressed.

It is completely permanent.

If a court wine stain is located on the face following the trigeminal nerve branches, the doctor must rule out Sturge -Weber syndrome, which has major neurological implications.

Finally, the strawberry hemangioma.

This is bright -rud, raised, rough -textured vascular tumor.

It typically grows larger for several months, which terrifies parents, but then it spontaneously regresses and disappears over several years.

Okay, we are entering the homestretch here.

The gestational age assessment, specifically the Ballard score.

This tool helps us figure out exactly how physically mature the baby is, whether they are actually 40 weeks or maybe just 36 weeks, entirely regardless of the mother's calculated due date.

Exactly.

Sometimes dates are wrong.

The Ballard score uses specific neuromuscular and physical maturity signs to objectively calculate the true gestational age.

It's considered clinically accurate to within two weeks.

Let's do the neuromuscular signs first.

These are basically the physical flexibility tests.

1.

Posture.

We mentioned this.

A full -term baby rests tightly flexed up.

A preemie rests extended, relaxed, and floppy.

2.

Square window.

You take the baby's hand and gently flex the wrist down toward the forearm.

A mature term baby's hand can sold completely flat against the forearm, making a 0 degree angle.

A preemie has much stiffer wrist joints and the wrist won't bend as much, usually stopping at a 90 degree angle.

3.

Arm recoil.

You pull both of the arms, hold for a second, and quickly let go.

A term baby instantly snaps them right back up into flexion.

A preemie's arms will just lazily stay down.

4.

Palpatial angle.

You flex the baby's thigh flat onto their chest, and then firmly try to push the lower leg straight up.

Term babies have incredibly tight hamstrings.

You can't straighten the leg much past 90 degrees.

Preemies have zero resistance.

Their leg goes completely straight up in the air.

5.

Scarf sign.

You take the baby's hand and pull the arm directly across their chest toward the opposite shoulder.

In a preemie, the arm effortlessly wraps entirely around the neck, exactly like a scarf, and the elbow easily passes the midline of the chest.

In a term baby, the elbow simply will not reach the midline because their pectoral muscles resist the stretch.

6.

Heel to ear.

While they are lying flat, you gently pull the baby's foot straight up toward the ear on the same side.

Term babies are way too stiff and flexed for this.

Preemies, however, are essentially little yoga masters.

Their foot will go right up and practically touch the ear with no resistance.

So the basic rule of thumb to remember for exams.

Term equals heavily flexed and physically stiff.

Preterm equals totally floppy and highly flexible.

Exactly.

You've got it perfectly.

And the other half of the Ballard score is the physical maturity signs.

Right.

1.

Skin.

Preemies have incredibly sticky, friable, transparent skin, where you can clearly see the underlying veins.

Post -term babies have thick, leathery, cracked, and severely peeling skin because they lost their protective vernix too early.

2.

Lenugo.

That fine hair is most abundant right around 28 weeks gestation, and then it progressively thins out completely by term.

3.

Plantar surface.

You closely examine the soles of the feet.

A preemie's foot is completely smooth with no lines.

A full term baby has deep creases covering the entire length of the sole from top to bottom.

4.

Breasts.

You look at and physically palpate the breast tissue bud.

Term babies have raised, stippled areola and a distinct palpable breath bud that you can actually measure with a tape measure.

Usually 5 to 10 millimeters.

Preemies have a totally flat areola and barely perceptible nipples with no palpable tissue underneath.

5.

Eyes and ears.

In a very, very premature infant, the eyelids might actually still be physically fused shut.

For the ears, you fold the upper can of the ear down forward.

In a term baby, the ear cartilage is thick, so the ear springs back upright instantly.

A preemie's ear cartilage is extremely soft and developed, so the ear just stays folded over.

6.

Genitals.

Just as we mentioned during the physical exam, term males have deep rugae and fully descended testes.

Preemie males have smooth scrotums and undescended testes.

Term females have a labia majora that completely covers the labia minora and clitoris.

Preemie females have a very prominent clitoris and small, widely separated labia majora.

So the nurse performs all these checks, scores them on the

chart, adds the numbers all up, and gets an incredibly accurate gestational age.

Okay, finally, let's talk about behavior.

A newborn baby isn't just a physical robot.

They have dynamic behavioral states.

Right.

They go through very predictable reactivity periods in the hours right after birth.

The first period of reactivity happens immediately right after birth.

The baby is wide awake, alert, highly active, and usually very hungry.

Their eyes are wide open, exploring the room.

This is the absolute golden hour for initiating breastfeeding and promoting deep maternal -infant bonding.

But then, they hit the period of sleep.

They crash hard.

They completely crash.

Their vital signs drop to a low normal baseline, they fall into a very deep sleep, and it is almost impossible to wake them up to feed.

After a few hours of that, they enter the second period of reactivity.

They wake up again, become highly active, and this is typically when they might gag or spit up a large amount of excess mucus.

So, the nurse needs to have the bulb syringe ready.

And despite being so new, they actually have genuine social and cognitive capabilities from day one.

They really do.

The text highlights a few incredible ones.

Orientation.

They can actually fixate on and visually follow a human face or a bright object.

Habituation.

This is a brilliant protective mechanism.

If there is a constant repetitive annoying noise in the nursery or bright lights, the newborn brain can completely tune it out so the baby can sleep and protect themselves from sensory overload.

And finally, self -consoling.

A crying baby will instinctively bring their hand or fist straight to their mouth to suck on it to naturally calm themselves down without any adult intervention.

Wow.

Okay, we just exhaustively covered an entire chapter.

That was comprehensive.

We truly walked through the entire admission assessment from the absolute first priority of catching their breath and clearing the airway all the way down to assessing their neurological reflexes, to deciphering the meaning behind specific skin spots and birthmarks.

If you are listening to this on your way to a test or clinicals, you might really want to pause and just re -listen to those highly specific sections like the distinct visual signs of respiratory distress, the pathologic versus physiologic jaundice timelines, or that massive breakdown of the Ballard score.

Those are incredibly high yield topics that instructors love for nursing exams.

Absolutely.

Because truly understanding exactly what normal looks and feels like is the only way you will instantly be able to spot the abnormal when a baby is actually struggling.

That is the true art and science of a brilliant nursing assessment.

Before we go, I want to leave you with a final thought to mull over, building on what we just discussed.

Think about how many of these seemingly random reflexes, like the morrow startle or the strong palmar grasp, are actually deep ancient evolutionary holdovers.

For early hominids, a baby's ability to instinctively physically cling to a mother's fur when startled could literally be the difference between life and death.

Even today, the maternal infant dyad functions almost as a single biologically synchronized organism long after the umbilical cord is cut.

It is a completely fascinating physiological reality.

That is an amazing perspective to carry with you into the nursery.

Thank you so much for joining us on this incredible deep dive.

A huge, warm thank you from the entire Last Minute Lecture team for tuning in and trusting us with your prep.

Good luck with your studies, your exams, and your clinical rotations.

You've completely got this.

See you next time.