Standard Newborn Evaluation From The Newborn Nursery Orientation Manual

This post contains The Standard Newborn Evaluation template or checklist from The Newborn Nursery Orientation Manual Updated 2014* from the University of Viriginia Children’s Hospital.

*This link downloads the entire manual to your computer. The manual is an excellent newborn memory aid. I’ve included the Table of Contents:

  1. Standard Newborn Evaluation


1. Date, time and location of birth, referring MD/hospital
2. Birth weight
3. Sex, race
4. Gestational age (EGA)

  • by dates (mother’s estimate)

  • by pre-natal exam (obstetrician’s estimate) (i.e. serial fundal heights, first fetal heart tone, sonography)

  • by post-natal exam – Ballard assessment (estimate)

5. Mother’s age and history of previous pregnancies (Gravid = # pregnancies; Para = # births; AB = # abortions,
spontaneous or therapeutic; living = # children living – summarized, for example, as G3, P2, AB1, L2)
6. Blood types of mother and baby, Coombs test, mother’s antibody screen; ABO & Rh incompatibility
7. Maternal Labs

  • VDRL

  • Hepatitis B

  • HIV

  • GC, chlamydia

  • Group B strep status

  • Amniocentesis-genetic or for lung maturity

8. Complications of pregnancy, labor and delivery

  • Maternal illness/infections

  • Use of drugs, prescribed and non-prescribed

  • Alcohol and smoking

  • Duration of labor/premature labor – tocolytic drugs

  • Duration of rupture of membranes – evidence of maternal infection/colonization culture results/ antibiotic therapy

  • Type of delivery – spontaneous vaginal (SIVA), forceps, C-section

  • Characteristics of amniotic fluid – oligohydramnios, polyhydramnios, meconium stained

  • Abnormal presentation

  • Fetal monitoring

  • Anesthesia used

9. APGAR scores at one and five minutes and every five minutes thereafter until score exceeds six

10. Neonatal course to date

11. Social history

  • Where mother lives

  • Role of father in family

  • Other members of the household

  • Financial support

  • Emotional support

12. Plans for feeding – breast or bottle

13. Plans for well child care and immunizations

Physical Exam

1. Vital signs, measurements
(descriptive terms: T, P, R, BP; Wt, length, head circumference, including percentiles)
2. General appearance

  • level of activity (active/lethargic)

  • general perfusion and color (pink/blue/mottled/pale/yellow; edematous/dehydrated; well developed)

  • nutritional status/state of hydration

  • gross abnormalities

3. Skin

  • vernix

  • capillary hemangiomas (benign): most common on eyelids, forehead, back of neck –
    occasionally on trunk or extremities

  • mongolian spots (benign)

  • cafe-au-lait spots: > 5 suggestive of neurofibromatosis (if all > 1.5 cm in diameter)

  • milia: superficial epidermal inclusion cysts – generally on face

  • erythema toxicum

  • “parchment skin”: seen in post-term babies

  • dryness, turgor: assess hydration

  • petechiae

    • common, benign: usually on face and upper body – occurs 2° intra-thoracic pressure as the chest passes through the birth canal

    • uncommon: pathologic as a result of thrombocytopenia; important to note distribution and watch for progression

  • “sucking blisters”: hands

  • abrasions

  • peeling of skin in postmature baby

  • jaundice

4. Head

  • shape

  • molding

  • asymmetry: may be normal 2° fetal posture or abnormal 2° structural defect

  • appearance

  • bruising

  • scalp: internal monitor sites, scalp blood sampling sites

  • forceps marks

  • hair distribution

  • palpation

  • caput succedaneum: diffuse, generally symmetric scalp edema 2° vertex presentation (usually resolves in first few days); edema crosses sutures

  • cephalohematoma: sub-periosteal hemorrhage; feels like boggy edema but is located over one particular bony area; may take months to resolve; never crosses sutures; can indicate linear skull fracture or more occult intracranial bleeding

  • sutures: craniotabes is a soft area in parietal bone near the sagittal suture

  • palpable fractures

5. Fontanelles

  • anterior and posterior

  • may suggest increased intracranial pressure if bulging open wide fontanelle extending into frontal area

6. Eyes

  • may be hard to assess in first 24 hours due to edema of lids

  • reactiveness of pupils (PERRL = Pupils equal, round, reactive to light)

  • red reflex exam for retinoblastoma, corneal opacities

  • lens

  • test for congenital cataracts

  • discharge

  • conjunctival hemorrhage: common, may be benign; occurs 2° increase in intra-thoracic pressure when the chest passes through the birth canal

  • inter-canthal distance: if increased or decreased may suggest a congenital syndrome

7. Ears

  • external appearance: shape and position

    • low set ears may suggest a congenital syndrome such as Down syndrome

  • external canals: check for patency, atresia

  • tympanic membranes: canals may be too tortuous to allow visualization

  • preauricular sinus and tags: may be associated with renal anomalies/hearing loss             

8. Nose 

  • external appearance: congenital abnormalities, atresia

  • flaring of nostrils: may suggest respiratory distress

  • patency of nares: congestion/discharge

9. Mouth

  • external appearance: cleft lip, shape, etc

  • precocious dentition (supernumerary teeth)

10. Palate

  • structural abnormalities

  • cleft: may lead to feeding problems aspiration etc. in the immediate neonatal period

  • high arched: may suggest congenital syndrome

  • lesions

    • Epstein Pearls: whitish nodules on palate; benign, common; accumulation of epithelial cells

11. Neck

  • tone: increased may indicate neurological disease

  • palpitation: masses include thyroid, cystic hygroma, branchial cleft/cysts

  • mobility: congenital torticollis (may palpate mass as well)

12. Chest

  • appearance

    • congenital deformities may cause asymmetry

    • retractions: sub-xiphoid or intercostal suggest respiratory distress with increased effort of breathing

  • respiratory pattern: rate and rhythm commonly quite variable; > 60 resp/min for sustained time is abnormal

13. Lungs

  • auscultation

    • rales, wheezes, rhonchi, grunting

    • compare air movement on each side and between lung zones

14. Heart

  • cyanosis: central vs acrocyanosis     

  • precordial activity

  • rhythm and rate (RRR = regular rate and rhythm)

  • commonly quite variable

  • may range from 100-180 in various states of rest/activity

  • extra systoles and sinus pauses common

  • S1, S2: may be grossly abnormal in valvular heart disease

  • murmurs

    • murmur = m

    • grade I-VI (written e.g. II/VI)

    • describe location and quality

    • murmurs in first day from a closing ductus are common

    • any murmur still present on third day should be evaluated 

  • gallops

  • extra heart sounds very difficult to hear at the rapid heart rate of a newborn

15. Pulses

  • palpate in each extremity and compare side to side and UE to LE

  • decrease in LE pulse or delay in transmission to LE vs UE may indicate coarctation of the aorta

  • pulse graded 0-4+: 0 = Absent, 2+ = Normal, 4+ = Bounding

16. Abdomen

  • observation: distended, discolored, scaphoid

  • bowel sounds: may not be present early in life

  • palpation: for masses, distension etc.

  • umbilicus: number of cord vessels

  • liver: commonly palpable up to 1 cm below the right costal margin

  • spleen: may be just palpable under left costal margin

  • kidneys: usually palpable, at least in part, in a very relaxed infant who allows deep palpation; palpable large kidneys suggestive of hydronephrosis

17. Genitalia

  • inspection

    • examine all structures to ascertain if they are clearly male or female

    • particularly check for location of the urethral orifice; may be displaced (hypospadias, epispadias) in what appears to be male infant (may be male or virilized female)

    • foreskin is often tight and appears closed

    • female genitalia may appear enlarged in proportion to the other body structures 2° the effects of maternal hormones and/or prematurity

  • palpation

    • palpate for testes in the scrotum or inguinal canal

    • scrotal enlargement may be 2° hydrocele which is relatively common – diagnose by transillumination as well as palpation (intermittent, recurrent hydrocele is suggestive of hernia)

    • testes may be in canal or not palpable in ELBW infant

  • discharge

    • females may have a clear mucous discharge or even blood (“pseudomenses”) 2° hormonal stimulation in utero with sudden withdrawal in post-partum

  • circumcision

    • may look quite edematous and erythematous

    • watch for difficulty urinating after procedure

18. Breasts: may not be visible in ELBW; term infant may have prominent breast tissue, hormonally stimulated

19. Rectum: check for patency (evidence of stooling), fissures (may see bloody stools), placement (may be

20. Hernia: check inguinal regions; diastasis recti (midline weakness of the abdominal musculature) is common
and may simulate a ventral hernia

21. Spine

  • inspect and palpate for deformity, deviation

  • inspect for dermal sinus tracts: may be anywhere along the midline from the nose, over the skull and down the spine to the sacrum

  • any dimple should be carefully examined to be sure that the bottom of the pit is visible (traction on the skin helps exam)

  • any discoloration or hairy lesion should be evaluated

22. Clavicles: inspect for asymmetry; palpate for fractures (common birth trauma)

23. Extremities 

  • inspect for deformities – fetal position may cause some apparent abnormalities that are self-correcting

  • check joints or observe for range of motion: term infants are normally quite flexed as a general posture

  • check palmar creases

  • hips – test for congenital dysplasia by:

  • observing for differences in leg movement

  • check for differences in leg length

  • checking for asymmetry of leg skin folds (misleading)

  • manipulation of the hips (abduction) with fingers over the greater trochanter and feeling for (or hearing) clicks

  • Barlow & Ortoloni maneuvers

  • Digits: count them; extra digit buds or skin tags are not uncommon (often familial)

24. Neuro

  • degree of alertness

  • spontaneous movement

  • posture

  • tone

  • grasp, suck, Moro, root

  • DTRs

  • response to light, sound

  • facial, brachial plexus palsies

25. Cord (Umbilicus)

  • check for secure clamping

  • count and document the arteries (2, thick-walled) and vein (single, thin walled) in the remnant

26. Voiding

  • 95% of infants void in the first 24 hours

  • 98% void in the first 48 hours

  • most common reason for “delay” in voiding is missing urination at birth

27. Stools

  • 90% of infants pass stool in the first 24 hours

  • 98% stool in the first 48 hours

  • prolonged time without stooling suggests meconium ileus (cystic fibrosis), meconium plug, or other congenital defect

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