a major responsibility immediately following delivery is to determine the condition of the newborn infant the nerve should use a systematic approach to assess the infants transition to life outside the uterus non eye protection and gloves because there may be a risk of contact with maternal blood or fluids as well as fetal secretions place the infant in a warmer quickly dry the infant to prevent heat loss from evaporation remove the wet linen and leave the infant uncovered to facilitate warming and observation the initial assessment called the Apgar score is completed at one minute and repeated at five minutes following birth if the infant is stable there are five components heart rate respiratory effort muscle tone reflex irritability and skin color the Apgar score is a quick determination of the physiological status of the newborn during app car scoring the newborn is given a score from 0 to 2 for each category auscultate the apex of the heart to determine the heart rate if the rate is above 100 per minute give the infant a score of 2 if less than 100 a score of 1 and 0 if there is no heart rate heart rate can be assessed by palpating the umbilical cord assess respiratory effort by observing respirations and auscultate in the chest give a score of 2 if the infant is crying vigorously or if the respirations are spontaneous and regular 1 if the effort is weak or irregular and 0 if there is no effort evaluate muscle tone of a full-term infant by noting the amount of flexion well flexed extremities receive a score of 2 some flexion a score of 1 and if the infant is flaccid the score is 0 determine the infant's reflex irritability by gently tapping the sole of the infant's foot and observing the response a responding cry receives a score of 2 a grimace receives a score of 1 and no response scored zero assess the infant's color by checking for both central and peripheral cyanosis if the Caucasian infant is completely pink indicating oxygenated blood right the score as a to reduce the score to 1 if the hands and feet are bluish which is not unusual if the infant is pale or if the body or face is cyanotic the score is zero because non-caucasian infants may appear ashen or gray observe the mucous membranes of the lips mouth and tongue for central cyanosis at five minutes reassess the infant on all five Apgar points again total all five components of the assessment a score of eight nine or ten indicates satisfactory cardiopulmonary adaptation and requires no specific intervention scores between five and seven indicate the need for stimulation and the administration of oxygen with bag and facemask a score of seven and or below often requires a repeat assessment and scoring at ten minutes of life resuscitation will be required if the score is below four if the baby's app car score and condition are satisfactory proceed with a brief physical examination which begins with scanning the infant's head back and extremities for obvious anomalies such as cleft lip or palate and polydactyly or extra fingers or toes check the umbilical cord the stump is normally bluish white in color the arteries are usually easy to find because arterial tissue is tough and erectile the vein appears as a large flat opening count the umbilical blood vessels there should be two arteries and one vein one infant in every 500 may have only one artery life can be sustained with one artery but this finding may be indicative of other congenital anomalies one-third of which are related to kidney problems this finding should be reported to the physician for further evaluation make sure the cord clamp is tightly closed follow agency policy regarding care of the umbilical stump often no further care is needed identification bands with matching imprinted numbers should be placed on the baby and the parents do foot or hand printing if agency policy at this point the baby can be swaddled in warm blankets have placed on head and given to parents or the blankets can be removed and skin-to-skin contact started to maintain the infant's temperature and promote bonding between the infant and mother in some hospitals the infant is weighed and measured in the delivery room or the baby may be taken to the nursery in either location the process is the same major weight and length 0 the scale with a pad or towel in place prior to placing the baby on the scale this will protect the infant from losing heat to the scale surface lift the infant by placing one hand carefully under the back and head place the infant on the scale and make sure no foreign objects are touching the scale be careful to prevent the infant from falling by placing your hand above the infant while on the scale record weight in both pounds and grams use the printed ruler on the scale or a tape measure to determine the infant's length measure from crown to rump and then from rump to heel as you extend the newborns leg and dorsiflex the foot gently measure to the bottom of the heel record in both inches and centimeters place the baby in a preheated warmer place a skin probe on the abdomen and cover the end of the probe with an adhesive patch made specifically for this purpose be sure the warmer is in skin or servo mode the bed will automatically heat up or cool down based on the baby's skin temperature do not cover the temperature probe with blankets or clothing as that will affect the temperature reading vital signs for an accurate temperature reading if using the axilla hold the thermometer in the center of the axillary space with the infant's arm positioned over it creating a good seal by securely holding on to the arm so the baby does not move it normal temperature range for axillary route is thirty-six point five to thirty seven point five centigrade ninety seven point seven to ninety nine point five Fahrenheit axillary is the preferred route taking a rectal temperature may be necessary if it is impossible to get an accurate axillary temperature and it may be hospital protocol to take a rectal temperature to assess for anal patency this should be done gently with a thermometer not inserted beyond the sensor maintain optimum temperature by preventing heat loss this is a priority for newborns as their skin to muscle mass ratio is increased and heat is quickly lost through exposed skin to check heart rate and heart sounds more clearly use a pediatric stethoscope this eliminates some extraneous noise and permits more accurate evaluation you can use a pacifier to quiet a crying infant count the heart rate for a full minute over the apex of the heart the normal rate should be 110 to 160 beats per minute it may be higher if the baby is crying in addition to the heart rate listen for abnormal heart sounds such as murmurs or arrhythmias if unsure about distinguishing abnormal from normal sounds ask another nurse to recheck heart sounds before recording your findings during the initial assessment check brachial pulses by palpating both sides simultaneously for rate and intensity also check femoral pulses on both sides press the fingers gently over the groin areas to palpate if it is difficult to feel femoral pulses you may be pressing too hard in the femoral area thereby occluding the artery ask for help if necessary while assessing a newborns breathing note that respirations are often irregular with periods of apnea if the infant is quiet you can assess visually if the baby is crying count respirations with the hand placed lightly on the chest normal respiratory rate is between 30 to 40 respirations per minute in many facilities blood pressure measurement is not taken on newborn infants check the agency policy use a Doppler instrument or electronic blood pressure monitor and a cuff of the appropriate size to provide the most accurate information if required the initial blood pressure is done on all four extremities and may be repeated if you notice increased capillary refill time unequal peripheral pulses or lethargy normal blood pressure in a newborn is 65 to 95 systolic and 30 to 60 diastolic blood pressure that does not fall within these normal parameters or pressure that is lower in the legs than in the arm should be rechecked and if still abnormal reported to the physician begin head to toe physical examination to assess the head elevate it slightly while supporting the back and neck palpate the head for size shape and symmetry check for molding the fetal head is composed of five major bones that are molded and become elongated as the head passes through the birth canal following birth the bones of the skull may overlap slightly this is called overriding sutures the head may appear deformed and the fontanel's or soft spots where the bones join may feel smaller than expected palpate both the diamond shaped anterior fontanelle approximately 2 to 4 centimeters and the triangular posterior fontanelle approximately 0.5 to 1 centimeter with the infant in an upright position a depressed fontanel indicates dehydration while a bulging one may be a sign of increased inter-cranial pressure also check for Capet succedaneum a localized area of edema that overlies cranial sutures lines this occurs as a result of the head pushing on the cervix the swelling will disappear within one to three days infants can also develop a cephalo hematoma due to pressure on the head during birth this problem results from bleeding that occurs between the periosteum and the cranial bones and may be noted on one or both sides of the head unlike Capet sucks edenian the swelling that results does not cross the suture lines reassure parents that the condition resolves without treatment major head circumference around the occiput and just over the eyebrows normal ranges are 33 to 35 point 5 centimeters or 13 to 14 inches daily measurements may be necessary if the head is unusually large and the healthcare team is concerned about hydrocephalus carefully lift the head to remove the tape measure to prevent skin laceration check the eyes for color which is usually slate grey dark blue or brown in non-caucasian infants pupillary responses should be equal that is both pupils should constrict or dilate at the same time when a light is shined in either check for a red reflex in both eyes with an ophthalmoscope this validates that lenses are intact observe for subconjunctival bleeding or edema of the eyelids that may occur during birth also assess for eye drainage next note the location of the ears the top of the penis' should be horizontal to the outer canthus of the eye low-set ears may suggest chromosomal abnormality or fetal alcohol syndrome and require further investigation skin tags are frequently observed near the ears call this to the attention of the physician these may be insignificant or associated with renal malformations also inspect the ears to see if they are well-formed and complete inspect the nostrils for discharge because infants must breathe through their nose check for patency hold the mouth closed while blocking one nostril and observing respirations repeat the process while blocking the other nostril it is also important to observe the nose for flaring which occurs when the Nerys expand to inhale more oxygen in addition to palpating for an intact lip and palate check the mouth for symmetry of movement when the infant cries or sucks drooping of one side of the mouth may indicate paralysis of the facial nerve which may affect movement of the tongue this problem can occur during a traumatic delivery and should be further evaluated small white hard cysts called Epstein's pearls are often visible on the palate or gums these appear during fetal development are normal and usually disappear spontaneously within one or two months if the infant has precocious teeth report your findings they are usually removed by the physician to prevent aspiration when they fall out also check for circumaural cyanosis a bluish discoloration around the lips and mouth it is important to note if the color improves with crying this may indicate a need for gentle stimulation to increase oxygenation increase cyanosis with crying or other activities such as feeding may be a sign of cardiac pathology assess the infant for adequate feeding reflexes particularly rooting and sucking to elicit rooting stroke the side of the infant's mouth with your finger the infant should move the mouth toward that side this reflex helps the infant find the nipple for feeding normal full-term infants should have a strong suck reflex that can be elicited by touching the lips or palate the reflex may be less active if the infant is preterm or ill assess for adequate suck swallow coordination assuring that infant is able to feed without difficulty assess the infant's posture proportion and color while she is quiet the healthy full-term infant should be flexed the head should be approximately 1/4 the total size and the legs are proportionately small the infant's color should be consistent with ethnic background although acrocyanosis or blue coloration of the hands and feet is common for the first few hours and is not considered abnormal until 24 hours of life some skin variations are normal and require no treatment these include stork bites localized areas of capillary dilatation usually seen on the back neck eyelids or between the eyebrows the parents should be reassured that these disappear by 2 years of age Millia caused by distended sebaceous glands appear as small whitish papules on the nose chin and forehead many non Caucasian infants have irregular areas of deep blue pigmentation on the lower back or buttocks these are called Mongolian spots observe the infant's neck it should be short thick and surrounded by skin folds report webbing of the neck or an obvious fat pad between the head and back these findings may indicate a variety of syndromes which would need to be investigated the head should turn easily from side to side fracture of the clavicle is one of the most common birth injuries particularly if the infant is large and passage through the birth canal was difficult to check for this move your fingers slowly and carefully over the surface of the clavicle to determine if it's intact a palpable lump or grading sensation may indicate a fracture observe the arms for symmetrical movements because there can be paralysis of the arm on the side of the fracture paralysis may also occur due to brachial plexus injury during birth report abnormal findings to the physician assess the chest by noting if it is cylindrical in shape and the xiphoid cartilage is visible at the end of the sternum check the size placement and number of nipples supernumerary nipples can occasionally be seen in both male and female infants some infants have enlarged breast tissue due to maternal hormones the breast tissue will decrease in size in a few days place the tape at the nipple line to measure chest circumference the average circumference is thirty point five to 33 centimeters or twelve to thirteen inches approximately two to three centimeters smaller than the head when finished lift the infant away from the tape rather than pulling the tape from under her as this may cause a small laceration palpate the infant's abdomen it should be soft round and symmetrical auscultate for bowel sounds in all four quadrants these are usually audible within a few hours after birth major abdominal circumference just above the umbilicus circumference varies with the size of the infant observe for abdominal size which seems out of proportion to the size of the infant observe for abdominal distension and loops of bowel if these or localized bulging are noted this may indicate bowel obstruction bulging around the cord remnant may suggest umbilical hernia both should be reported to the physician only experienced personnel should evaluate the infant for hip dysplasia which is the slipping or displacement of the head of the femur this is done by placing the fingers over the greater trochanter x' and thumbs over the inner thighs exert gentle pressure to flex the thighs and rotate them outward if hip dysplasia is present the head of the femur can be felt to slip forward in the acetabulum and slip back when pressure is released and the legs return to their normal position an audible click called Ortolani's sign is sometimes heard inspect the extremities for length and size relative to each other if the infant cries when the extremities are palpated suspected fracture also check for symmetrical skin folds on both legs to initiate the Moro or startle reflex hold both of the infants hands and gently raise the baby a short distance the baby's back should be off the mattress but head should still touch then let the hands go in response both arms should extend and abduct while the fingers fan open with the thumb and forefinger forming a C position asymmetrical movement of the arms maybe due to fracture of the clavicle as described earlier or to damage to the brachial plexus the tonic neck reflex is a normal response in newborns place the infant supine quickly turn the head to one side the infant should extend the arm and the leg of the body on the side to which the head is turned the limbs on the other side of the body should flex the reflex prevents the infant from rolling over until adequate neurologic and motor development has taken place it will disappear in two or three months absence or persistence of this reflex may indicate central nervous system damage to inspect the fingers spread them and check for webbing count the fingers note the condition of the skin peeling skin on the hands may indicate the infant may have been born after 40 weeks gestation inspect the palms for a single palmar line or simian crease that may indicate the chromosomal disorder Down syndrome or trisomy 21 place your finger in the neonates palm this should elicit the palmar reflex count the toes and check for webbing check the ankles and feet for excessive in curving or restricted movements that may be due to intrauterine positioning this may also suggest club foot or talipes aquinas press a finger against the base of the neonates toes they should curl downward in a plantar grasp reflex stroke the bottom of the foot from the heel towards the toes to elicit the Babinski reflex the toe should hyper extend and fan outward while the great toe dorsi flexes although the Babinski reflex disappears at about one year of age absence at birth may indicate neurological problems to examine the back place the infant in a prone position the back should appear straight and flat palpate the vertebral column to check for alignment bulges or masses an indentation or Tufts of hair are associated with spina bifida or spina bifida occulta two types of defective closure of the vertebral column examine the lower sacrum for dimpling that may indicate a pilonidal cyst which can develop in the sacral region of the skin while the infant is in the prone position check that the legs can be straightened and inspect for equal length and for symmetry of gluteal folds unequal length or asymmetrical folds are indications of hip dislocation this should be reported to the pediatrician usually the genitals and anus are assessed last in female infants the labia are often at dimittis particularly if the birth was breech separate the labia majora and inspect the labia minora and clitoris for size and location you may note a considerable amount of vernix which is often present in the labial folds a vaginal or hymen 'el tag may be present these will disappear in a few weeks a vaginal discharge of thick whitish mucus may be noted and within a few days of birth there may be some bloody vaginal discharge this is called pseudo menstruation it is due to the withdrawal of them internal hormones and it is normal to confirm that the infant is voiding at least six to eight times a day keep a record of the number of wet diapers document first void notify the physician if the infant has not voided within the first 24 hours of life inspect the penis to determine if the urinary meatus is correctly positioned at the end of the glans penis hypospadias which occurs when the urinary meatus is located on the under surface of the penis requires corrective surgery and should be reported to the physician keep a record of voiding and wet diapers check the scrotum for size and symmetry palpate each side of the scrotum separately between the thumb and forefinger with the other hand placed over the inguinal canal to verify that the testes have descended into the scrotal sac hydrocele a collection of fluid surrounding the testes is common in newborns inspect the anal area last to verify that it is patent and has no fissures the passage of the first stool Atari bowel movement called meconium should occur within the first 24 hours after birth this should be recorded notify the physician if the infant has not passed the first stool by 48 hours of life additional newborn screening tests are done one of these is to determine whether neonates may be at risk for bleeding problems a blood sample obtained by heel stick is checked for a determination of haemoglobin this may be routinely done upon admission to the nursery or only if there is a concern of respiratory distress or infection a blood glucose level should also be checked a result of 40 milligrams per deciliter requires immediate intervention another blood sample is obtained by heel stick to screen for as many as 37 disorders including cystic fibrosis an exocrine disorder several metabolic and endocrine disorders such as phenylketonuria galactosemia org my acid disorder and congenital adrenal hyperplasia and hemoglobin disorders such as sickle cell disease at the completion of the physical examination and within an hour after birth by medication should be instilled to prevent ophthalmic neonate Oram an infection of the eyes caused by exposure to gonorrhea or chlamydia during passage through the birth canal an injection of vitamin K is also administered because neonates are unable to synthesize vitamin K for the first few days of life this completes the physical exam all findings should be documented according to agency protocol and observations indicating abnormalities or concerns should be reported to the physician and parents performing thorough assessments along with the knowledge of common alterations and their causes give the nurse than necessary knowledge and skills to thoroughly evaluate the infant in the first few minutes of life identification of potential problems can be done early so that collaboration with other members of the healthcare team provides the best possible intervention and outcome for the newborn