When performing a newborn assessment the nurse should measure the vital signs in the following sequence * 1 point?

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After birth, newborn babies are carefully checked for problems or complications. Throughout the hospital stay, physicians, nurses, and other care providers continually assess each infant for changes in health and signs of illness.

One of the first assessments is a baby’s Apgar score. At one minute and five minutes after birth, infants are checked for heart and respiratory rates, muscle tone, reflexes, and color. This helps identify babies that have difficulty breathing or have other problems that need further care.

Complete Physical Exam

Because birth weight is an important indicator of health, babies are weighed daily in the nursery. This indicates their growth, as well as their fluid and nutritional needs. Newborn babies may lose as much as 10 percent of their birth weight.

In addition, each newborn undergoes a complete physical examination. Care providers evaluate vital signs, including temperature, pulse, and breathing rate. They also check the infant’s general appearance from head to toe, looking at everything from soft spots on the skull to breathing patterns to skin rashes to limb movement. Your baby’s head circumference, abdominal circumference, and length will also be measured.

Your Baby’s Maturity

Maturity assessment is helpful in meeting a baby’s needs if the dates of a pregnancy are uncertain. For example, very small babies may actually be more mature than they appear by size and may need different care than premature babies.

An examination called the Dubowitz/Ballard Examination for Gestational Age is often used. This check evaluates a baby’s appearance, skin texture, motor function, and reflexes. The physical maturity component of the exam is conducted within the first two hours of birth. This looks at your baby’s skin, eyes, ears, chest, genitals, and feet, since these areas of the body look different at different stages of maturity.

Next, within 24 hours after delivery, the Dubowitz/Ballard Examination looks at six aspects of the baby’s neuromuscular system. These include:

• Posture

• How far the hands can be flexed toward the wrist

• How far the arms spring back to a flexed position

• How far the knees extend

• How far the elbows can be moved across the chest

• How close the feet can be moved to the ears

Additional Tests

After birth, all newborns receive eye drops or an antibiotic ointment in their eyes. This is required by law to protect the baby from an unknown gonorrhea infection in the mother.

Most babies also receive a vitamin K injection in the upper thigh. Vitamin K is an essential component of blood clotting. The injection helps prevent a serious problem called vitamin K deficiency bleeding.

Finally, nearly all babies will have a simple blood test to check for disorders that are not apparent immediately after delivery. Some of these disorders are genetic, metabolic, or blood- or hormone-related. Your newborn may also undergo a hearing test.

All of these examinations are important ways to learn about your baby’s well-being at birth. By identifying any problems, your baby’s physician can plan the best possible care.

Online Medical Reviewer: Louise Jovino, DO

Date Last Reviewed: 4/6/2010

© 2000-2018 The StayWell Company, LLC. 800 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.

© 2000-2018 The StayWell Company, LLC. 800 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.

Learn how to assess vital signs on an infant!

As a pediatric nurse, you will be required to know how to assess vital signs on many different pediatric populations, such as the newborn (infant). This review will detail how to assess the respiratory rate, heart rate, temperature, weight, length, head circumference, and chest circumference.

Assessing Vital Signs on a Newborn (Infant)

Vital Signs on an Infant

When collecting vital signs on an infant you will want to keep the following in mind:

• Start with the most non-invasive vital sign first.
  • Sequence for assessing an infant’s vital signs:
    • Respirations, heart rate, temperature, weight, length, head circumference, chest circumference
  • Supplies needed:
    • Infant size stethoscope
    • Watch for counting
    • Thermometer
    • Scale
    • Measuring tape
  • Sanitize supplies before and after use, perform hand hygiene before and after assessment

Respirations

• Normal respiratory rate: 30-60 breaths per minute
• Assess for any signs of distress: nasal flaring, chest retractions, skin color, <30 or >60 breaths per minute
• Count for one full minute: at this age the rate is irregular so you need to count for 1 full minute. Infants have what is called periodic breathing (this is where the infant breathes and stops for a few seconds and then breathes again).
• Watch the rise and fall of the chest….one rise and one fall equals one breath
  • Tip: infants are abdominal breathers so watch this area or lightly place a hand on the area while counting
    
    Credit: RegisteredNurseRN.com

Heart Rate:

• Use an appropriate size diaphragm and bell for the infant
• Normal heart rate
  • Less than a month old: 100 to 190 bpm (varies on if sleeping or crying)
  • One month to year old: 90-180 bpm
• Count the apical pulse by auscultating for 1 full minute
  • Infants can experience sinus arrhythmia which is associated with respirations….the heart rate speeds up and down with respirations.
  • The apical pulse on an infant is found at the 4th intercostal space (ICS), lateral to the midclavicular line….remember in the adult it was the 5th ICS.
    
    Credit: RegisteredNurseRN.com

• The heart rate is going to be fast so it will take you practice when learning how to count the heart rate on an infant.

Temperature

• Normal temperature range for an infant: 36.4-37.4 ‘C (97.5-99.3 ‘F)
• Route taken is via the armpit…axillary
  
  Credit: RegisteredNurseRN.com

• Place the tip of the thermometer within the fold of the armpit and close the arm and wait for the thermometer to beep.

Weight

• Remove clothing and soiled diaper (can keep a dry diaper on the infant)
• Place infant on the scale and obtain weight
• Compare current weight to previous weights
  
  Credit: RegisteredNurseRN.com

Length

• May need another person to help hold the infant still as you mark the length
• Measure from head to heel and place paper behind infant to mark length areas
• Lay baby back…keep head midline and extend a leg…mark these areas on the paper and measure with measuring tape.
• Normal length 18-22 inches
  
  Credit: RegisteredNurseRN.com

Head Circumference

• Use a measuring tape and measure in centimetres
• Measure the largest diameter of the head. This is found around the forehead (just above the eyebrows) and the prominent part of the back of the head.
• Normal: 33 cm to 38 cm
  
  Credit: RegisteredNurseRN.com

Chest Circumference

• Use a measuring tape and measure in centimetres
• Wrap the measuring tape around the infant’s chest and use the nipple line as a guide.
• The chest circumference should be about 1-2 cm less than the head circumference.
  
  Credit: RegisteredNurseRN.com

References:

Center for Disease Control and Prevention. (2016). Measuring Head Circumference [Ebook] (p. 1). Retrieved from https://www.cdc.gov/zika/pdfs/Microcephaly_measuring.pdf

Growth Charts – Clinical Growth Charts. Retrieved 3 August 2020, from https://www.cdc.gov/growthcharts/clinical_charts.htm

Infant Guidelines | Height & Weight Measurement. Retrieved 3 August 2020, from https://www.ihs.gov/hwm/infantguidelines/