NCLEX Review & Nursing School

   Newborn  Assessment

1. Airway

1. Bulb suction (mouth->nose)

2. APGAR score

1. 0-3 poor

2. 4-6 fair

3. 7-10 excellent

3. Measurements

1. Wt- 6-9lb

2. Length-19-21in, 48-53cm

3. Head circumference 13-14in

4. Chest- 1” < head circumference

4. VS

1. T no rectal, axillary 97.7-99.7

2. HR 100BPM (sleep), 120-160bpm (awake), up to 180 bpm (crying)

3. Resp 30-60

4. BP 65/41

5. Skin

1. Erythematous (beefy red)

1. Color for a few hrs after birth

2. Bluish discoloration

1. Hands and feet-norm 24hr

2. Vernix caseosa

1. Protective gray-white fatty substance of cheesy consistency covering fetal/NB skin

3. Lanugo

1. Downy, fine hair over shoulder, head, cheeks

4. Milia

1. Distended sebaceous gland

2. Tiny white pinpoint papules on forehead, nose, cheeks, and chin

3. Disappear spontaneously in a few day/wks

5. Pigmentation

1. Mongolian spots

1. Bluish gray/dark nonelevated pigmentation area over the lower back and buttocks (+) at birth in some infants

2. Birthmarks

1. Telangiectatic nevi “stork bite”

1. Capillary dilation on eyelids, nose, nape of neck (small, flat)

2. Can be blanched by the pressure of the finger

3. Fade during infancy

2. Nevus vasculosus “strawberry mark”

1. Raise, demarcated, dark red, rough-surfaced capillary hemangioma indural and subural layers

2. Grow rapidly first few months and then fade, disappear by 7yo

3. Nevus flammeus “port wine stain”

1. Reddish, usually flat discoloration common face/neck

2. Doesn’t grow/fade