Nb Assessment Essay Example

unequal pulses (coarctation of the aorta), and the location of murmurs should be noted. Abnormal rates, rhythms, sounds, and pulses should be referred.

RespirationsRate ranges from 30 to 60 breaths per minute (average 40 to 49 BrPM). Respirations are irregular, shallow, but not difficult. Chest movements appear equal on both sides. Breath sounds are audible and normal on both sides. The patient experiences rapid breathing, particularly after the first hour, indicating respiratory distress. The patient also has slow respirations possibly due to maternal medications.

The following respiratory distress symptoms can occur:
- Nasal flaring
- Grunting
- Gasping
- Periods of apnea lasting more than 20 seconds or with changes in heart rate or color
- Asymmetry or decreased chest expansion
- Intercostal, xiphoid, supraclavicular retractions, or see-saw (paradoxical) respirations.
These symptoms may indicate various conditions such as respiratory distress syndrome, respiratory depression, sepsis, cold stress, or pneumothorax.

Moist, coarse breath sounds like crackles and rhonchi indicate the presence of fluid in the lungs, while hearing bowel sounds in the chest may suggest a diaphragmatic hernia. It is crucial to closely monitor slight changes in these symptoms as they generally improve within a few hours after birth. However, if the symptoms persist or worsen, it is necessary to perform suctioning, administer oxygen, contact a physician, and initiate more intensive care measures.

Blood Pressure: Blood pressure levels can vary depending on factors such as age, weight, activity level, and gestational age.

The average systolic pressure ranges from 65 to 95 mm Hg and the average diastolic pressure ranges from 30 to 60 mm Hg. Hypotension caused by hypovolemia, shock, or sepsis is identified. A difference of 20 mm

Hg in blood pressure between the arms and legs indicates coarctation of the aorta. Any abnormal blood pressures should be referred for further evaluation.

Prepare for intensive care and very low.

MeasurementsWeight2500-4000 g (5 lbs. 8 oz. to 8 lbs. 13 oz.).

In the early days, weight loss of up to 10% is observed. Factors contributing to high weight loss include low gestational age (LGA) and maternal diabetes, while low weight loss is associated with being small for gestational age (SGA), preterm birth, multifetal pregnancy, and medical conditions affecting fetal growth. Weight loss exceeding 10% is usually connected to dehydration and feeding problems.

Determining the cause is crucial. Complications commonly linked to the cause should be monitored. The length measures at 48-53 cm (19-21 inches), which is considered below normal in cases of SGA and congenital dwarfism.

Above normal (LGA, maternal diabetes). Determine cause. Monitor for complications common to cause.
Head Circumference32-38 cm (12.5-15 inches). Head and neck are approximate of the infants body surface. Small (SGA, microcephaly, anencephaly-absence of large part of brain or skull).

Determine cause

Large (LGA, hydrocephalus, increased intracranial pressure).

Monitor for complications common to cause. Chest Circumference 30-36 cm (12-14 inches). Is 2 cm less than head circumference.

Monitor for complications common to cause.

Posture: Extremities are flexed and able to move freely, resist extension, and quickly return to a flexed state. The hands are typically clenched. Movement is symmetric. In addition, there may be slight tremors when crying.

When held, a baby with extended and stiff legs molds their body to the caregiver's body

and quiets down when their needs are met. On the other hand, preterm babies, those with hypoxia or on certain medications may have limp, flaccid, floppy, or rigid extremities. In cases of neonatal abstinence syndrome or CNS injury, babies may exhibit hypertonicity. Jitteriness or tremors may be observed in babies with low glucose levels impacting their calcium levels.

Opisthotono is the extreme hyperextension of the body accompanied by seizures and stiffness when held. This condition is related to CNS injury. When present, it is important to identify and refer any abnormalities. Increased intracranial pressure can be indicated by a high-pitched cry. Neurologic problems may manifest as weak, absent, irritable, or cat-like "mewing" sounds.

Hoarse or crowing (laryngeal irritation) should be observed for changes in reported abnormalities. The skincolor should be pink or tan with acrocyanosis (cyanotic discoloration of extremities), and there may be vernix caseosa found in creases.

There are small quantities of lanugo present on the shoulders, sides of the face, forehead, and upper back, which is fine and soft downy hair. The skin turgor is good and quickly recoils. There is some cracking and peeling of the skin.

Normal variations: Milia, which are tiny white bumps, and skin tags.

Erythema toxicum, also known as "flea bite" rash, can be observed. There may be puncture marks on the scalp from the electrode. Mongolian spots are present. The color variations of the skin include cyanosis of the mouth and central areas, which may indicate hypoxia. Facial bruising may be present due to a nuchal cord. Pallor can be observed, indicating anemia or hypoxia. Gray skin color may suggest hypoxia and hypotension. In very preterm infants, the skin may appear red,

sticky, and transparent. A greenish brown discoloration of the skin, nails, and cord could indicate potential fetal compromise in postterm infants. Harlequin coloration is considered a normal transient autonomic imbalance. Mottling on the skin can be normal or may indicate cold stress, hypovolemia, or sepsis. Jaundice should be monitored, especially if it appears within the first 24 hours after birth. Yellow vernix may suggest blood incompatibilities, while thick vernix is more common in preterm infants.

Delivery marks can include bruises on the body due to pressure, on the scalp from vacuum extraction, or on the face due to a cord around the neck. Petechiae may be present and can indicate pressure, low platelet count, or infection. Forceps marks are also possible.

Birthmarks such as Mongolian spots may be observed.The following are different types of skin conditions: Nevus simplex (salmon patch, stork bite), Nevus flammeus (port-wine stain), Nevus vasculosus (strawberry hemangioma), and Cafe au lait spots (6+) larger than 0.5cm in size (neurofibromatosis).

In addition, other skin issues include excessive lanugo (preterm), excessive peeling and cracking (postterm), pustules or other rashes (infection), and "tenting" of the skin (dehydration). It is important to differentiate patient bruising from cyanosis.

Central cyanosis necessitates the use of suction, administration of oxygen, and additional medical intervention. It is important to refer to jaundice occurring within the first 24 hours or jaundice that is more extensive than what is typically seen for the age of the individual. It is crucial to monitor infants with meconium staining for any respiratory issues. Additionally, it is important to be vigilant for signs and potential complications associated with preterm or postterm birth.

When examining the skin, record the location, size,

shape, color, and type of rashes and marks. It is important to differentiate Mongolian spots from bruises. Use forceps to check for facial movement and look for jaundice with bruising. Additionally, make sure to point out and explain normal skin variations to parents. Also, remember to palpate the head sutures, which may have a small separation between each.

The anterior fontanel, which is diamond-shaped and measures 4-5 cm, is soft and flat. It may exhibit a slight bulge when the baby cries. In contrast, the posterior fontanel is triangular in shape and measures 0.5-1 cm.

The hair has a silky and soft texture with individual hair strands. There are normal variations including:

• Overriding sutures (molding).
• Caput succedaneum or cephalohematoma (pressure during birth).
• The head can be large (hydrocephalus, increased intracranial pressure) or small (microcephaly).
• Sutures can be widely separated (hydrocephalus) or there can be a hard, ridged area at sutures (craniosynostosis - a birth defect that causes one or more sutures on a baby's head to close earlier than normal).
• The anterior fontanel can be depressed (dehydration, molding), or it can be full or bulging at rest (indicating increased intracranial pressure).
• Woolly, bunchy hair is common in preterm babies. Unusual hair growth can indicate genetic abnormalities.

It is important to seek the cause of these variations. Observe for signs of dehydration with a depressed fontanel and signs of increased intracranial

pressure with bulging fontanel and wide separation of sutures. Referral for treatment is necessary. Differentiate between Caput succedaneum and cephalohematoma, and reassure parents that these variations are normal and do not indicate any negative outcome.

Observe for jaundice with cephalohematoma. Ears well-formed and complete. Area where upper ear meets head even with imaginary line drawn from outer canthus of eye. Startle response to loud noises. Alerts to high-pitched voices. Low set ears (chromosomal disorders).

The individual has skin tags, pre-auricular sinuses, and dimples. These may be linked to kidney or other abnormalities. Additionally, there is deafness indicated by the lack of response to sound. It is crucial to examine for abnormal voiding when there are ear irregularities. If the positioning is abnormal, signs of chromosomal abnormality should be sought after. Referral for evaluation is recommended if there is no response to sound.

Face Symmetry and Abnormalities

Symmetry in appearance and movement of the face is crucial. The parts of the face should be properly placed and proportional. Asymmetry, which can be caused by pressure imposition in utero, can result in drooping of the mouth or one side of the face, leading to a one-sided cry due to facial nerve injury. Chromosomal abnormalities can also cause abnormalities in facial features.

Checking the delivery history is important for identifying possible causes of facial nerve injury.

• The eyes should be symmetric.
• The eyes should be clear.
• Transient strabismus may occur.
• The baby may have scant or absent tears.

The pupils should be equal and react to light. Additionally, the baby should show interest in looking at things. The Doll's eye sign, which

refers to a reflex movement of the eyes opposite to that of the head, indicates functional integrity of brainstem tegmental pathways and cranial nerves involved in eye movement.

Red reflex is the reddish-orange reflection of light that comes from the retina of the eye. It can occur with subconjunctival hemorrhage or edema of the eyelids due to pressure during childbirth. Inflammation or discharge may indicate chemical or infectious conjunctivitis. Moreover, a blocked lacrimal duct can cause excessive tearing.

Unequal pupils, failure to follow objects (blindness), white areas over pupils (cataracts), and setting sun sign (downward deviation of the eyes) indicate increased intracranial pressure or irritation of the brain stem (hydrocephalus).

• Yellow sclera signifies jaundice.
• Blue sclera is a result of osteogenesis imperfecta, a condition causing extremely fragile bones.

Clean and monitor any drainage and seek the cause.

Reassure parents that subconjunctival hemorrhage and edema will clear. Refer any other abnormalities.

Nose - Both nostrils open to air flow. There may be slight flattening from pressure during birth. Blockage of one or both nasal passages (choanal atresia).

Malformations (congenital conditions) may lead to flaring and mucus, causing respiratory distress. It is important to observe for any signs of respiratory distress and report any malformations. Additionally, the mouth, gums, and tongue should be pink.

The tongue is normal in size and movement. The lips and palate are intact, and there are sucking pads. The newborn has functioning sucking, rooting, swallowing, and gag reflexes.

Normal variations include:

There may be precocious teeth and Epstein's pearls, which are multiple small white epithelial inclusion cysts typically found in the midline of the palate in most newborns.

The presence of cyanosis, which is a sign

of hypoxia, can be observed. There may also be white patches on the cheek or tongue, indicating candidiasis. If a person has Down syndrome, their tongue may appear protruding. Additionally, diminished movement of the tongue and a drooping mouth can be signs of facial nerve paralysis.

Cleft lip, palate or both, as well as absent or weak reflexes (preterm, neurologic problem) and excessive drooling (tracheoesophageal atresia) may require oxygen for cyanosis. It is important to expect the removal of loose teeth and obtain an order for antifungal medication to treat candidiasis.

Inspect the mother for any infections in the vagina or breasts and refer any abnormalities. Ensure the infant demonstrates good coordination between sucking and swallowing during feeding and keeps the feedings. In case of prematurity, be aware of poorly coordinated suck and swallow. If the infant experiences duskiness or cyanosis during feeding, this may indicate cardiac defects.

Choking, gagging, and excessive drooling are symptoms of tracheoesophageal fistula and esophageal atresia. It is advised to feed slowly and stop frequently if any difficulties arise. Suction and stimulate the infant if necessary. Infants with persistent difficulties should be referred for further evaluation.

Neck/Clavicles

Short neck enables easy side-to-side head movements, as the infant raises their head when in a prone position. The clavicles remain intact without any issues. Any muscle abnormalities such as weakness, contractures, or ridgidity should be noted. Conditions like chromosomal disorders may present with webbing of the neck or a large fat pad at the back of the neck.

Common signs of a clavicle fracture include crepitus, a lump, or crying when the clavicle or other bones are palpated. There may

also be diminished or absent arm movement. Clavicle fractures are more frequent in large infants who experienced shoulder dystocia during birth. It is important to immobilize the affected arm and look for any other associated injuries. If any abnormalities are found, referral to a specialist is necessary. Additionally, the chest may take on a cylinder shape.

Xiphoid process may be noticeable and in alignment. Nipples are present and positioned correctly. There may be engorgement and white discharge from the nipples due to maternal hormone withdrawal.

Asymmetry, such as diaphragmatic hernia or pneumothorax, and supernumerary nipples should be reported due to the potential of redness indicating infection.

Abdomen is rounded and soft with bowel sounds present within the first hour after birth. The liver can be palpated 1-2cm below the right costal margin. The skin is intact and there are 3 vessels in the cord.

Clamp tight and cord drying. Meconium passed within 12-48hr. Urine generally passed within 12-24h. Normal variation: "Brick dust" staining of diaper (uric acid crystals).

• Sunken abdomen (diaphragmatic hernia).
• Distended abdomen or loops of bowel visible (obstruction, infection, and large organs).
• Absent bowel sounds after first hour (paralytic ileus).
• Masses palpated (kidney tumors, distended bladder).
• Enlarged liver (infection, heart failure, hemolytic disease).
• Abdominal wall defects (umbilical or inguinal hernia, omphalocele, gastroschisis, exstrophy of bladder).
• Two vessels in cord (other anomalies).
• Bleeding (loose clamp).
• Redness,
  

drainage from cord (infection).

Refer abnormalities. Assess for other anomalies if only two vessels in cord.

Make sure to tighten the loose cord clamp or replace it if necessary. If there is any abnormal stool or urine output, check for any missed recording, increase the frequency of feedings, and report it.

Genitals

The female labia majora appear dark in color and they cover the clitoris and labia minora. There is a small amount of white mucus vaginal discharge.

Urinary meatus and vagina are present. Normal variations include vaginal bleeding (pseudomenstruation).

• Hymenal tags.
• Clitoris and labia minora are larger than labia majora (preterm).
• Large clitoris (ambiguous genitalia).
• Edematous labia (breech birth).

Check gestational age for immature genitalia. Refer anomalies.

Male Testes within scrotal sac, rugae on scrotum, prepuce nonretractable.

• Meatus at tip of penis.
• Testes in inguinal canal or abdomen (preterm, cryptorchidism).
• Lack of rugae on scrotum (preterm).
• Edema of scrotum (pressure in breech birth).
• Enlarged scrotal sac (hydrocele).
• Small penis, scrotum (preterm, ambiguous genitalia).
• Empty scrotal sac (cryptorchidism).

Nails should be positioned at the ends of the digits or slightly beyond, indicating good muscle tone.

• Fractures may be indicated by crepitus,

redness, lumps, or swelling.

Any anomalies should be referred and further examination should be conducted. For the upper extremities, two transverse palm creases are expected.

• A simian crease may be normal or indicate Down syndrome.
• Diminished movement suggests injury.
• Erb-Duchenne paralysis may be indicated by diminished movement of the arm with extension and forearm prone.

Any anomalies should be referred and further examination should be conducted.

Lower Extremities Legs are equal in length, abduct equally, have equal gluteal and thigh creases, and have equal knee height. There is no hip "clunk". The feet are in a normal position.

• The Ortolani and Barlow tests show abnormalities, indicating unequal leg length, unequal thigh or gluteal creases (suggesting developmental dysplasia of the hip).
• The feet are malpositioned, potentially due to their position in utero (talipes equinovarus).

All anomalies should be referred and other abnormalities should be looked for. Malpositioned feet

should be checked to determine if they can be gently manipulated back to their normal position. Back No openings in the vertebral column are observed or felt. The anus is patent.

• The sphincter is tightly closed.
• There may be a failure of one or more vertebrae to close, which is known as spina bifida.
• Spina bifida may occur with or without a sac containing spinal fluid and meninges, which is called meningocele.
• Spina bifida may also involve a sac containing spinal fluid, meninges, and cord, which is known as myelomeningocele.
• The sac is enclosed.

There may be a tuft of hair over spina bifida occulta, or a pilondial dimple or sinus may be present. An imperforate anus is also possible. Any abnormalities should be referred for further evaluation. Movement below the level of the defect should be observed. If there is a sac, it should be covered with a sterile dressing dampened with sterile saline.

Protect from injury. Reflexes See table 21-3. | Absent, asymmetric or weak reflexes. | Observe for signs of fractures, nerve injury, or injury to CNS. | TABLE 21-3 SUMMARY OF NEONATAL REFLEXES *MCH page 493| REFLEX| METHOD OF TESTING| EXPECTED RESPONSE| ABNORMAL RESPONSE/POSSIBLE CAUSE| TIME REFLEX DISAPPEARS| Babinski| Stroke lateral sole of foot from heel to across base of toes. | Toes flare with dorsiflexion of the big toe.

No response. Bilateral: CNS deficit. Unilateral: local nerve injury. 8-9 months.

Gallant

(trunk incurvation): With infant prone, lightly stroke along the side of the vertebral column.

Entire trunk flexes toward side stimulated.

No response: CNS deficit.

| At 4 months of age, the infant exhibits the grasp reflex, which can be observed in both the palmar and plantar areas. | To test this reflex, gently press a finger against the infant's fingers or toes. | If the reflex is present, the infant's fingers will tightly curl, and their toes will curl forward. | The absence or weakness of this reflex may indicate a neurologic deficit or muscle injury. | The palmar grasp typically develops at 2-3 months of age, while the plantar grasp develops at 8-9 months. | Another reflex commonly seen in infants is the Moro reflex. | To elicit this reflex, let the infant's head drop back slightly. |

30?. | There is sharp extension and abduction of the arms followed by flexion and adduction to the "embrace" position. | There is no CNS dysfunction present.

Assymetry:

This can be due to brachial plexus injury, paralysis, or a fractured bone of the extremity.

Exaggerated:

This can be due to maternal drug use.

The rooting reflex can be tested by touching or stroking the side of the infant's mouth towards the cheek. When this is done, the infant will turn their head in the direction of the touch. However, it may be difficult to observe this reaction if the infant is asleep or has just been fed.

Some factors that can weaken or cause the absence of the rooting reflex include:

prematurity, neurologic deficit, and depression resulting from maternal drug use.

At 3-4 months, when you

hold the infant so their feet touch a solid surface, they will lift alternate feet as if walking.

Asymmetry: This refers to a fracture of an extremity or a neurologic deficit at 3-4 months.

Sucking: To encourage sucking, you can place a nipple or gloved finger in the infant's mouth and rub it against the palate.

The infant starts to suck and may be weak if recently fed. Weakness or absence of sucking may be caused by prematurity, neurologic deficit, or maternal drug use. By the age of 1, the infant should be able to swallow. To test swallowing, place fluid on the back of the tongue and observe if the infant swallows the fluid.

Coordination with sucking is necessary and can result in symptoms such as coughing, gagging, choking, and cyanosis. These symptoms can be caused by several conditions including tracheoesophageal fistula, esophageal fistula, esophageal atresia, and neurologic deficit.

These symptoms are present throughout life. The tonic neck reflex can be observed by gently turning an infant's head to one side while they are lying on their back. The infant will extend their extremities on the side to which their head is turned, with flexion on the opposite side. A prolonged period in this position can cause a neurologic deficit. The tonic neck reflex may be weak at birth but typically disappears by 4 months of age.