Which assessment finding of a newborn requires prompt action by the nurse?
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Cardiac murmurs should be evaluated as to intensity (grades 1 to 6), timing (systolic or diastolic), location, transmission, and quality (musical, vibratory, or blowing): Show
The murmur grade is recorded as 1/6, and so on. The next step in evaluating a murmur is its classification in relation to S1and S2. The three types of murmurs are systolic, diastolic, and continuous. An infant with no murmur may still have significant cardiac disease. Systolic Murmurs Most heart murmurs are systolic, occurring between S1 and S2. Systolic murmurs are either ejection or regurgitation murmurs. They are a normal finding during the routine physical exam of a healthy infant. Studies have shown that as many as 90% of healthy children have a benign murmur at some time. The blood flow causes ejection murmurs through stenotic or deformed valves or increased flow through normal valves. Regurgitant systolic murmurs begin with S1, with no interval between S1 and the beginning of the murmur. Regurgitation murmurs generally continue throughout systole. Regurgitation systolic murmurs are caused by blood flow from a chamber at a higher pressure throughout the systole than in the receiving chamber. Regurgitation systolic murmurs are associated with only three conditions:
Diastolic Murmurs Diastolic murmurs are classified according to their timing in relation to heart sounds as early diastolic, mid-diastolic, or pre-systolic. They are usually pathologic. They result from aortic regurgitation and pulmonary insufficiency. With aortic regurgitation, the murmur is high-pitched and blowing. It begins with the second heart sound and is loudest in early diastole. It may be missed because it is often very soft or may be mistaken for breath sounds because of its high pitch. Bounding pulses are present. The murmur of pulmonary insufficiency is a distinctive diastolic murmur. It is low-pitched, early in onset, and of short duration. It ends well before the first heart sound. It occurs with postoperative TOF, pulmonary hypertension, postoperative pulmonary valvotomy for pulmonary stenosis, or other deformities of the pulmonary valve. Mid-diastolic murmur results from abnormal ventricular filling. Due to stenosis, the murmur results from turbulent flow through the tricuspid or mitral valve. They are associated with mitral stenosis or large left-to-right shunt VSD or PDA, producing relative mitral stenosis secondary to increased flow across the normal-sized mitral valve. It is seen in the atrial septal defect (ASD), total or partial anomalous pulmonary venous return (TAPVR, PAPVR), endocardial cushion defects, or abnormal stenosis of the tricuspid valve. Continuous Murmurs Most continuous murmurs are not audible throughout the cardiac cycle. They begin in systole and extend into diastole. They are a pathologic finding. They can be produced in rapid blood flow, high-to-low pressure shunting, and localized arterial obstruction. The most significant is the PDA high-to-low shunting. The patency of the ductus is normal in the first 24 hours of life, but a few weeks later, a patent ductus is abnormal. It is more common in girls (sex ratio of 3:2), tends to affect siblings, and may be a complication of maternal rubella. It is six times more common in infants born at high altitudes and more common in premature infants. There may be a vigorous pericardial activity, a systolic thrill, and bounding pulses if the ductus is large. There may be symptoms of congestive heart failure (CHF). A full newborn nursing assessment should include measurements such as weight, length, head circumference, and vital signs. The assessment should start by generalizing the infant’s appearance, including position, movement, color, and breathing (Overview, 2020). During this general observation, the RN should identify any apparent deformities, how the baby moves, their color while resting, and their respiratory effort (nasal flaring, grunting, retractions in the chest). The skin should be assessed for abnormalities such as areas of abnormal pigmentation, congenital nevi, macular stains, or hemangiomas. Vesicles, bullae, and pustules in the newborn may be caused by infections, congenital disorders, or other diseases (Reginatto et al., 2017). Milia are white papules that resolve within a few weeks. These are the most common problem with the skin and are harmless. The head should be assessed next and looked for symmetry. The fontanelles should be soft and flat. The sutures of the skull should be felt. There may be molding from the birth canal, but if this lasts longer than 2 to 3 days after birth, there may be a problem. Caput succedaneum is an area of edema on the head. This area may be present at birth, crosses suture lines, and resolves within a few days. Cephalohematomas are collections of blood that are present in 1 to 2 percent of newborns. On palpation, they form a fluctuant mass that does not cross suture lines, which may increase in size after birth, and usually take weeks to months to resolve. Subgaleal hemorrhages are blood collections between the aponeurosis covering the scalp and the periosteum. Subgaleal hemorrhages extend across suture lines but feel firm and fluctuant. Blood loss from these hemorrhages can be life-threatening and should be evaluated immediately (UpToDate, 2019). The face should be assessed for symmetry. The eyes should also be assessed for symmetry, spacing, and movement. The ears should be assessed for symmetry and to ensure they are parallel to the eyes and not a common set, indicating a problem. The nose should be assessed for patency. The mouth should be examined for any cleft or abnormality. This examination includes palpation of the palette. A small jaw could also indicate a problem. The neck is palpated for masses, and the clavicles are palpated for crepitus, which could indicate an injury. The chest should be examined for size, shape, and symmetry. A malformed chest could indicate a problem. Retractions may be observed with respiratory difficulty. Breast size and location should be assessed. The lungs should be auscultated while the infant is quiet. Respirations should be observed and counted for a full minute. Heart rate should be assessed with a stethoscope while listening for murmurs. The femoral pulse should also be palpated. The abdomen should be assessed for shape. Any abnormal distention should be reported to the provider, as this could indicate a problem with the infant. The umbilical cord is evaluated to ensure it is clean without any signs of infection, such as redness or discharge. The genitalia should also be observed. The size and location of the labia, clitoris, meatus, and vaginal opening should be assessed in the female infant. The labia minora and clitoris are prominent in preterm infants, while the labia majora becomes larger as the infant approaches the term. A male infant should evaluate the presence of testes, size of the penis, appearance of the scrotum, and the position of the urethral opening. A newborn who has had a circumcision should be assessed for excessive bleeding or signs of infection. One or both undescended testicles should be reported to a provider. A male urethra with the abnormal ventral placement of the urethral opening is hypospadias. A newborn with hypospadias should not have circumcision and should see a urologist. The anus is examined for patency. Imperforate anus is not always visible. A baby who has not passed meconium and has a distended abdomen needs urgent evaluation by a provider. A small sacral dimple may be normal, but a larger dimple needs evaluation. The extremities should be assessed for proper movement and to ensure there are 5 fingers on each hand and 5 toes on each foot. The hips should be evaluated. The Ortolani and Barlow maneuvers use adduction and posterior pressure to feel for dislocation and abduction and elevation to feel for reduction. Newborn pain should be assessed every time the newborn gets vital signs and during a painful procedure, such as circumcision, according to hospital policy. This pain should be evaluated using a validated tool. There are many options available (Assessment, 2019). Which assessment of the newborn should be reported quizlet?What symptom assessed in the newborn shortly after delivery should be reported? Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
What is the highest priority in the newborn assessment quizlet?Rationale: The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
What is a normal newborn assessment?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.
Which assessment finding is expected as part of the normal newborn transition period?The majority of newborns complete the process of transition with little or no delay. These infants may demonstrate normal transitional findings, including tachypnea and tachycardia, a soft heart murmur and fine crackles in the lungs as well as acrocyanosis for varying lengths of time after birth.
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