Neonate Physical Assessment

Question 1

1st A in APGAR and scoring

Answer 1

Appearance
0 = cyanosis or pallor over entire body
1 = normal except for extremities
2 = entire body normal

Question 2

P in APGAR and scoring

Answer 2

Pulse
0 = absent
1 = less then 100 bpm
2 = greater then 100 bpm

Question 3

G in APGAR and scoring

Answer 3

Grimace (irritability)
0 = unresponsive
1 = grimace
2 = cries, sneezes, coughed, and recoils

Question 4

2nd A in APGAR and scoring

Answer 4

Activity (muscle tone)
0 = absent
1 = flex limbs
2 = infant moves freely

Question 5

R in APGAR and scoring

Answer 5

Respiration
0 = absent
1 = bradypnea, dyspnea
2 = good breathing and crying

Question 6

head vs chest circumference

Answer 6

the head is usually 2cm greater then chest circumference

Question 7

normal neonate RR

Answer 7

30-60 per min

Question 8

normal HR in neonate

Answer 8

120 - 160 while awake; 100 bpm asleep; 180 bpm while crying

Question 9

normal chest circumference

Answer 9

30-36cm

Question 10

normal head circumference

Answer 10

32-38 cm

Question 11

normal length

Answer 11

45-55cm

Question 12

what is the PMI

Answer 12

point of maximal intensity (heart sound location ) - neonate its between the 4th intercostal space and the midclavicalar line

Question 13

how to properly fit a blood cuff on a neonate

Answer 13

25% wide then the width of the infants arm in the area it will be applied

Question 14

hypertension in neonates

Answer 14

SBP greater then 90, DBP greater then 50; these values are lower in preterm

Question 15

how should MAP correlate with preterm infants

Answer 15

MAP should match the gestational age of the infant; example 28 week preterm should have a MAP of 28

Question 16

if the S1 is louder then normal it means…and name 3 causes

Answer 16

cardiac blood flow is higher; conditions that cause this are penitent ductus arteriosus, ventricular septal defects, and tetralogy of fallot

Question 17

if S1 is softer or quieter than normal…and what are 2 causes?

Answer 17

lowered cardiac output; CHF and myocarditis

Question 18

what is the silverman-anderson index

Answer 18

used to elevate respiratory status; a score of 0 indicates normal findings and higher scores indicate resp distress

Question 19

when are bowel sounds usually present in a newborn?

Answer 19

30-60 mins after birth

Question 20

stomach capacity of a newborn

Answer 20

50-60ml

Question 21

stool colors for breastfeed neonates

Answer 21

yellow gold and mushy

Question 22

stools in formula fed neonates

Answer 22

pale yellow and pasty

Question 23

nervous flammeus birth mark

Answer 23

port win stain - unraised red purple lesion caused by capillaries below the epidermis

Question 24

nevus vasculosus birthmark

Answer 24

strawberry mark - capillary hemangioma, raised, dark red lesion

Question 25

acrocyanosis

Answer 25

slight cyanosis in hands and feet during the 2-6 hours after birth especially if chilled

Question 26

mottling in neonates

Answer 26

common for hrs to weeks after birth and may be related to long periods of apnea/chilling

Question 27

harlequin sign

Answer 27

deep color on one side of body for 1-20 mins usually

Question 28

erythema toxicum

Answer 28

perifollicular lesions, 1-3 mm white or yellow with pustule appears suddenly all over body mins palms and soles; usually goes away on own, cause unknown

Question 29

military

Answer 29

small raised white spots on face from exposed sebaceous glands; transient

Question 30

vernix

Answer 30

thick, waxy substance that is secreted by the sebaceous glands and mixed with sloughed off skin; starts being produced at 20 weeks, thick at 25-40wks gestation and then 42-44wks no vernix

Question 31

describe 24-26wk gestation skin

Answer 31

translucent, red, many visible blood vessels and scant vernix

Question 32

describe skin at 35-40wk gestation

Answer 32

deep cracks, no visible blood vessels, and thick vernix

Question 33

describe skin at 42-44weeks gestation

Answer 33

dry, peeling skin, no vernix, and loss of subcutaneous fat

Question 34

neonatal feet should be….

Answer 34

flat

Question 35

neonatal hips should abduct to….

Answer 35

greater then 60 degrees

Question 36

palmer grasping

Answer 36

strokes the infants palm, infant responds by grasping the finger; strong in preterm infants and then fades; a sense indicates CNS deficit or muscle injury

Question 37

sucking reflex deficiency

Answer 37

premature infants may not have it because it develops around 32 weeks; absent may indicate CNS deficient or depression

Question 38

moro reflex

Answer 38

startle reflex; make a loud noise or give the infant a gentle jolt = extends arms, legs, and neck and then pulls arms and legs back, may cry; disappears at 5-6 months, asymmetric indicates peripheral nerve injury, fix of long bones, clavicle or skull

Question 39

tonic neck

Answer 39

fencing - with infants supine, turn head to one side = extremities flex on opposite side should and extend on same side

Question 40

how long do infants have babinski reflex?

Answer 40

up to 2 years old, after that toes flex

Question 41

stepping reflex

Answer 41

newborn is held upright and with the feet touching a horizontal surface, the contact should make the infant lift one foot and then the other, giving the appearance of walking; promotes muscle development and usually disappears in 4 months; if missing, may have motor nerve defect or other neurological abnormalities

Question 42

pull to sit test

Answer 42

Question 43

truncal tone test

Answer 43

Question 44

what is craniotabes?

Answer 44

area of soften skull found in 30% of all newborns (more common in preterm infants)

Question 45

caput succedaneum

Answer 45

collection of fluid beneath the skin but is superficial to the periosteum, swelling crosses suture lines; caused heading pressing against the suture lines during labor and by vacuum assisted deliveries

Question 46

cephalohemotoma

Answer 46

blood vessels between skull and periosteum rupture causing a subperiostel collection of blood; appears several hours after birth; !!!does not cross suture lines!!! if large can cause complications such as anemia and hypovolemia - blood eventually is reabsorbed and may cause jaundice