A complete inspection of the newborn infant is performed within 24 hours after delivery.

The goal is to compile a complete record of the newborn that will act as a database for subsequent assessment and care.

a. Assemble necessary equipment.

(1) Pediatric stethoscope.

(2) Penlight.

(3) Tape measure.

(4) Rectal thermometer.

(5) Infant scale.

b. Wash hands for a full three minutes.

c. Approach and identify the infant.

d. Provide for a warm, well-lighted, draft-free area, keeping the infant undressed for as short a time as possible.

e. Place the infant on a flat, protected surface.

f. Take the infant’s temperature.

The infant’s temperature is taken rectally only on admission. Subsequent temperatures are to be taken by the axillary method.

g. Determine the infant’s apical heart rate.

Count for a full minute.

h. Determine the infant’s respiratory rate.

Count for a full minute. Note any signs of respiratory distress (retractions, grunting, nasal flaring) rate over 60 bpm, or periods of apnea. Auscultate the infant’s lungs.

i. Balance the scale.

j. Weigh the naked infant.

Most newborns weigh between six to nine pounds (2,700 and 4,000 grams). Record the weight in pounds and ounces, as well as in grams.

k. Measure the infant’s length from top of the head to the heel with the leg fully extended and record measurements.

l. Measure the infant’s head circumference and record measurements.

The normal head circumference is 13 to 14 inches (33 to 35 cm). Cranial molding from a vaginal delivery may affect this measurement. The measurement should be repeated on the second and third day after delivery.

m. Measure the infant’s chest circumference at the nipple line and record the measurement.

n. Observe the general contour of the infant’s head.

Gently palpate the sutures and fontanelles. The anterior fontanelle is approximately two inches long and is gem/diamond shaped. The posterior fontanelle is smaller than the anterior fontanelle. Normally, the fontanelle feels soft and is either flat or slightly indented. The anterior fontanelle usually bulges when the infant cries, coughs, or vomits.

o. Observe the general appearance of the infant’s neck.

The infant’s neck is usually short, thick, and covered with folds of tissue. The infant should be able to move his neck from side to side, from flexion to extension, and can hold his head in the midline position.

p. Observe the infant’s eyes for symmetry of size and shape.

Note the infant’s eye movements. Strabismus caused by poor neuromuscular control is normal. An infant older than ten days should look in the direction in which you turn. Note the color of the infant’s eyes.

q. Inspect the infant’s ears for structure, shape, and position.

The ears should be firm with wee-formed cartilage. Tops of the auricles should be parallel to the outer canthus of the eye (refer to figure 7-5).

r. Inspect the infant’s nose for patency.

s. Inspect the infant’s mouth for cleft palate by gently depressing his tongue when he cries.

Check the mucous membranes. Observe the soft and hard palate. Make sure they are in tact.

t. Inspect the infant’s skin and nails.

Observe for jaundice, birthmarks, milia, petechiae, and lanugo. Observe the infant’s hands and feet for normal creases. Observe the color of the infant’s nail beds; they should be pink. Acrocyanosis may be present up to 24 degrees, especially when the infant is crying.

u. Inspect the size, shape, and symmetry of the infant’s chest.

Normally, an infant’s chest is circular or barrel-shaped. The breast tissue of both male and female infants may be slightly engorged during the first few days of life.

v. Palpate the infant’s peripheral pulses (femoral, brachial, and radial).

w. Inspect the size and shape of the infant’s abdomen.

The abdomen should be cylindrical in shape. Sunken or distended abdomen should be reported. Check the umbilical cord for the number of vessels.

x. Auscultate the infant’s abdomen for bowel sounds.

Bowel sounds should be present within one to two hours after birth.

y. Observe for excessive drooling, coughing, gagging, or cyanosis during feeding.

z. Place the infant on his abdomen and observe his spine for curves, masses, or abnormal openings.

aa. Inspect the male infant’s genitalia.

The penis should be checked for location of the urinary meatus. The scrotum may appear edematous and proportionately large.

bb. Inspect the female infant’s genitalia.

The labia majora may appear edematous and cover the clitoris and the labia minora.

cc. Observe the infant’s spontaneous or involuntary movements for symmetry, spasticity, or rigidity.

Gently straighten his arm or leg. Release it and observe whether it returns to its normal position. If the extremity remains limp, the infant may be hypotonic. If the extremity is difficult to straighten and rapidly flexes when released, he may be hypertonic.

dd. Dress the infant carefully and return him to his bassinet.

ee. Record all significant nursing observations in the infants’ health record.

Report your observations to the Charge Nurse.