NEONATAL ASSESSMENT DATA BASE (FULL-TERM)
(Refer to CP: The First Hour of Life.)
Activity/Rest
Wakeful state may be as little as 2–3 hr first several days.
Infant appears semicomatose while in deep sleep; grimacing or smiling is evident in rapid eye movement (REM) sleep; averages 20 hr of sleep per day.
Circulation
Apical pulse averages 120–160 bpm (115 bpm at 4–6 hr, rising to 120 bpm at 12–24 hr after birth); may fluctuate from 80–100 bpm (sleeping) to 180 bpm (crying).
Peripheral pulses may be weak (bounding pulses suggest patent ductus arteriosus [PDA]); brachial and radial pulses are more easily palpated than femoral pulses (absence of femoral and dorsalis pedis pulses suggests coarctation of the aorta).
Heart murmur often present during transition periods.
Blood pressure (BP) ranges from 60–80 mm Hg (systolic)/40–45 mm Hg (diastolic), average resting pressure approximately 74/46 mm Hg; BP lowest at 3 hr of age.
Umbilical cord clamped securely with no oozing of blood noted; shows signs of drying within 1–2 hr of birth, shriveled and blackened by day 2 or 3.
Elimination
Abdomen soft without distension; active bowel sounds present several hours after birth
Urine colorless or pale yellow, with 6–10 wet diapers per 24 hr
Passage of meconium stool within 24–48 hr of birth
Food/Fluid
Mean weight 2500–4000 g (5 lb 8 oz to 8 lb 13 oz);<2500 g suggests small for gestational age (SGA) (e.g., prematurity, rubella syndrome, or multiple gestation), greater than 4000 g suggests large for gestational age (LGA) (e.g., maternal diabetes; or may be associated with heredity). (Refer to CPs: The Preterm Infant; Newborn: Deviations in Growth Patterns).
Weight loss 5%–10% initially.
Mouth: Scant saliva; Epstein’s pearls (epithelial cysts) and sucking blisters are normal on hard palate/gum margins, precocious teeth may be present.
Neurosensory
Head circumference 32–37 cm; anterior and posterior fontanels are soft and flat.
Caput succedaneum and/or molding may persist for 3–4 days; overriding of cranial sutures may be noted, slightly obliterating anterior fontanel (2–3 cm in width) and posterior fontanel (0.5–1.0 cm in width).
Eyes and eyelids may be edematous; subconjunctival or retinal hemorrhage may be noted; chemical conjunctivitis lasting 1–2 days may develop following instillation of therapeutic ophthalmic drops.
Strabismus and doll’s eye phenomenon often present.
Top of ear aligns with inner and outer canthi of eye (low-set ears suggest genetic or kidney abnormalities).
Neurological Examination: Presence of Moro, plantar, palmar grasp, and Babinski’s reflexes; reflex responses are bilateral/equal (unilateral Moro reflex may indicate fractured clavicle or brachial plexus injury); transient crawling movements may be seen.
Absence of jitteriness, lethargy, hypotonia, and paresis.
Respiration
Transient tachypnea may be noted, especially following cesarean or breech birth.
Breathing Pattern: Diaphragmatic and abdominal breathing with synchronous movement of chest and abdomen (inspiratory lag or alternating seesaw movements of the chest and abdomen reflects respiratory distress); slight or occasional nasal flaring may be noted; marked nasal flaring, expiratory grunting, or marked retraction of intercostal, substernal, or subcostal muscles indicates respiratory distress; inspiratory crackles may persist for first few hours after birth (rhonchi on inspiration or expiration may indicate aspiration).
Chest circumference approximately 30–35 cm (1–2 cm smaller than circumference of head).
Safety
Skin Temperature: 96.8°F–97.7°F (36°C–36.5°C), rectal 97.8°F–99°F (36.6°C–37.2°C).
Skin Color: Acrocyanosis may be present for several days during transition period (general ruddiness may indicate polycythemia); reddened or ecchymotic areas may appear over cheeks or on lower jaw or parietal areas as a result of forceps application at delivery; facial bruising may be noted following precipitous delivery.
Cephalhematoma may appear day after delivery, increasing in size by 2–3 days of age, then be reabsorbed slowly over 1–6 mo.
Extremities: Normal range of motion in all; mild degree of bowing or medial rotation of lower extremities; good muscle tone.
Sexuality
Female Genitalia: Vaginal labia may be slightly reddened or edematous, vaginal/hymenal tag may be noted; white mucous discharge (smegma) or slight bloody discharge (pseudomenstruation) may be present.
Male Genitalia: Testes descended, scrotum covered with rugae, phimosis common (opening of prepuce narrowed, preventing retraction of foreskin over the glans).
Teaching/Learning
Gestational age between 38 and 42 wk based on Dubowitz criteria
DIAGNOSTIC STUDIES
White Blood Cell (WBC) Count: 18,000/mm3, neutrophils increase to 23,000–24,000/mm3 the 1st day after birth (decline occurs in sepsis).
Hb: 15–20 g/dl (lower levels associated with anemia or excessive hemolysis).
Hct: 43%–61% (elevation to 65% or over indicates polycythemia; decreased levels reflect anemia or prenatal/perinatal hemorrhage).
Guthrie Inhibition Assay: Tests for presence of phenylalanine metabolites, indicating phenylketonuria (PKU).
Total Bilirubin: 6 mg/dl on 1st day of life, 8 mg/dl at 1–2 days, and 12 mg/dl at 3–5 days.
Dextrostix: Initial glucose drop during first 4–6 hr after birth averages 40–50 mg/dl, raising to 60–70 mg/dl by day 3.
NURSING PRIORITIES
1. Facilitate adaptation to extrauterine life.
2. Maintain thermoneutrality.
3. Prevent complications.
4. Promote parent-infant attachment.
5. Provide information and anticipatory guidance to parent(s).
DISCHARGE GOALS
1. Newborn adapting effectively to extrauterine life.
2. Free of complications.
3. Parent-infant attachment is initiated and progressing satisfactorily.4. Parent(s) express confidence regarding infant care.
(Refer to CP: The First Hour of Life.)
Activity/Rest
Wakeful state may be as little as 2–3 hr first several days.
Infant appears semicomatose while in deep sleep; grimacing or smiling is evident in rapid eye movement (REM) sleep; averages 20 hr of sleep per day.
Circulation
Apical pulse averages 120–160 bpm (115 bpm at 4–6 hr, rising to 120 bpm at 12–24 hr after birth); may fluctuate from 80–100 bpm (sleeping) to 180 bpm (crying).
Peripheral pulses may be weak (bounding pulses suggest patent ductus arteriosus [PDA]); brachial and radial pulses are more easily palpated than femoral pulses (absence of femoral and dorsalis pedis pulses suggests coarctation of the aorta).
Heart murmur often present during transition periods.
Blood pressure (BP) ranges from 60–80 mm Hg (systolic)/40–45 mm Hg (diastolic), average resting pressure approximately 74/46 mm Hg; BP lowest at 3 hr of age.
Umbilical cord clamped securely with no oozing of blood noted; shows signs of drying within 1–2 hr of birth, shriveled and blackened by day 2 or 3.
Elimination
Abdomen soft without distension; active bowel sounds present several hours after birth
Urine colorless or pale yellow, with 6–10 wet diapers per 24 hr
Passage of meconium stool within 24–48 hr of birth
Food/Fluid
Mean weight 2500–4000 g (5 lb 8 oz to 8 lb 13 oz);<2500 g suggests small for gestational age (SGA) (e.g., prematurity, rubella syndrome, or multiple gestation), greater than 4000 g suggests large for gestational age (LGA) (e.g., maternal diabetes; or may be associated with heredity). (Refer to CPs: The Preterm Infant; Newborn: Deviations in Growth Patterns).
Weight loss 5%–10% initially.
Mouth: Scant saliva; Epstein’s pearls (epithelial cysts) and sucking blisters are normal on hard palate/gum margins, precocious teeth may be present.
Neurosensory
Head circumference 32–37 cm; anterior and posterior fontanels are soft and flat.
Caput succedaneum and/or molding may persist for 3–4 days; overriding of cranial sutures may be noted, slightly obliterating anterior fontanel (2–3 cm in width) and posterior fontanel (0.5–1.0 cm in width).
Eyes and eyelids may be edematous; subconjunctival or retinal hemorrhage may be noted; chemical conjunctivitis lasting 1–2 days may develop following instillation of therapeutic ophthalmic drops.
Strabismus and doll’s eye phenomenon often present.
Top of ear aligns with inner and outer canthi of eye (low-set ears suggest genetic or kidney abnormalities).
Neurological Examination: Presence of Moro, plantar, palmar grasp, and Babinski’s reflexes; reflex responses are bilateral/equal (unilateral Moro reflex may indicate fractured clavicle or brachial plexus injury); transient crawling movements may be seen.
Absence of jitteriness, lethargy, hypotonia, and paresis.
Respiration
Transient tachypnea may be noted, especially following cesarean or breech birth.
Breathing Pattern: Diaphragmatic and abdominal breathing with synchronous movement of chest and abdomen (inspiratory lag or alternating seesaw movements of the chest and abdomen reflects respiratory distress); slight or occasional nasal flaring may be noted; marked nasal flaring, expiratory grunting, or marked retraction of intercostal, substernal, or subcostal muscles indicates respiratory distress; inspiratory crackles may persist for first few hours after birth (rhonchi on inspiration or expiration may indicate aspiration).
Chest circumference approximately 30–35 cm (1–2 cm smaller than circumference of head).
Safety
Skin Temperature: 96.8°F–97.7°F (36°C–36.5°C), rectal 97.8°F–99°F (36.6°C–37.2°C).
Skin Color: Acrocyanosis may be present for several days during transition period (general ruddiness may indicate polycythemia); reddened or ecchymotic areas may appear over cheeks or on lower jaw or parietal areas as a result of forceps application at delivery; facial bruising may be noted following precipitous delivery.
Cephalhematoma may appear day after delivery, increasing in size by 2–3 days of age, then be reabsorbed slowly over 1–6 mo.
Extremities: Normal range of motion in all; mild degree of bowing or medial rotation of lower extremities; good muscle tone.
Sexuality
Female Genitalia: Vaginal labia may be slightly reddened or edematous, vaginal/hymenal tag may be noted; white mucous discharge (smegma) or slight bloody discharge (pseudomenstruation) may be present.
Male Genitalia: Testes descended, scrotum covered with rugae, phimosis common (opening of prepuce narrowed, preventing retraction of foreskin over the glans).
Teaching/Learning
Gestational age between 38 and 42 wk based on Dubowitz criteria
DIAGNOSTIC STUDIES
White Blood Cell (WBC) Count: 18,000/mm3, neutrophils increase to 23,000–24,000/mm3 the 1st day after birth (decline occurs in sepsis).
Hb: 15–20 g/dl (lower levels associated with anemia or excessive hemolysis).
Hct: 43%–61% (elevation to 65% or over indicates polycythemia; decreased levels reflect anemia or prenatal/perinatal hemorrhage).
Guthrie Inhibition Assay: Tests for presence of phenylalanine metabolites, indicating phenylketonuria (PKU).
Total Bilirubin: 6 mg/dl on 1st day of life, 8 mg/dl at 1–2 days, and 12 mg/dl at 3–5 days.
Dextrostix: Initial glucose drop during first 4–6 hr after birth averages 40–50 mg/dl, raising to 60–70 mg/dl by day 3.
NURSING PRIORITIES
1. Facilitate adaptation to extrauterine life.
2. Maintain thermoneutrality.
3. Prevent complications.
4. Promote parent-infant attachment.
5. Provide information and anticipatory guidance to parent(s).
DISCHARGE GOALS
1. Newborn adapting effectively to extrauterine life.
2. Free of complications.
3. Parent-infant attachment is initiated and progressing satisfactorily.4. Parent(s) express confidence regarding infant care.
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