Maternity - Newborn, part 2: Expected and Abnormal Findings of Newborn Assessment
by Meris Shuwarger BSN, RN, CEN, TCRN November 23, 2021 Updated: August 09, 2023 8 min read
Hi, I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about expected and abnormal findings in the newborn following birth. I'm going to be following along using our maternity flashcards, which are available on our website, leveluprn.com, if you want to get a set for yourself. And if you already have a set, I would invite you to follow along with me. Okay. Let's get started.
So first up, we're talking about the skin and expected and abnormal findings. So expected findings when it comes to the newborn, remember that they are adjusting to being alive on earth, right? It's a big task we have asked of them, and it's going to take some time. So it is expected for them to either have pink color or to have acrocyanosis, meaning that their trunk is pink but their extremities are a little bit bluish. This is normal as they adjust to extra-uterine life. And also this can happen in response to cold. It's really tough to have had mom circulating your blood for you and having a different circulatory setup, and now you're doing it all on your own and your circulation is the way it's going to be for the rest of your life. So that's a big, big deal there. Now, vernix and lanugo, so vernix is that sort of thick, creamy, almost like cheesy white substance that covers the infant. It protects the skin while they are in utero. So it is normal to find that, especially if we're talking about a full-term baby. They're not going to be covered in it, but they will have it in creases of the skin so maybe in their armpits or kind of in their neck rolls. That's very common. Now remember, lanugo is that fine downy hair that covers the fetal body. It helps with warmth and thermoregulation. And with a full-term baby, it is normal to still have some lanugo. You will typically find this in specific areas such as the sides of the face, the upper back of the newborn, and the shoulders as well. But remember, if you've seen the new Ballard video, we were talking about the fact that a premature infant will have abundant lanugo.
Okay. Abnormal findings, though, when it comes to the skin, a big one is going to be jaundice in the first day of life. So the first 24 hours after an infant is born, jaundice is always abnormal. If we develop jaundice later on, then we can talk about that in a little bit. But within the first 24 hours, it's always abnormal. It's bold. It's red here on the card. You know that that means that we think it's pretty important for you to understand. This is a big concept. Some other things would be green or brown discoloration of the skin and nails. That can indicate that meconium was passed inside the uterus, and that could indicate fetal distress.
Now let's talk about some normal variations of the skin. So these are not necessarily things that are expected findings, but they are not abnormal findings, either. They are normal variations. So telangiectatic nevi or the word that I would prefer because that was a mouthful, are stork bites. So these are kind of like a pink discoloration, and you'll see them a lot on infants on the eyelids, in between the eyes, on the neck, maybe the back of the head. And these will disappear with time, usually within 18 months. My daughter had one kind of right here above her eye. I thought it was very cute. It's completely gone now, but these are just from dilated capillaries. There's nothing bad or harmful about it. It's just a normal variation. Now milia, milia are little white cysts, and these can be found on the face of the newborn. Again, totally normal. They'll disappear in a few weeks. Nothing that needs to be done to treat them.
Now Mongolian spots or congenital dermal melanocytosis. This is essentially a blue or purple pigmentation of the skin that is typically found on the back or the buttocks of the newborn, and they kind of resemble bruising. But these are common in infants with darker skin because it has to do with more melanocytes in that area than normal, and melanocytes are the cells that produce melanin. So if I already have darker skin, I already have a higher number of melanocytes, and therefore, I am more at risk for having this melanocytosis, right? Again, these will fade within a couple of years. There is nothing bad or harmful about them at all, but your job as the nurse is going to be to document these, right? It's important to document this finding so that in the future, we can look back at the chart and say, "Yep, that's been present since birth," and not a sign of abuse, right? That would be important to know. Nevus flammeus or a port-wine stain, this is going to be like a purple or red discoloration, and you'll often see it on the face or the neck, and this is permanent. This is not harmful in any way, but this is going to be lifelong. And then erythema toxicum, this is a transient rash. It has papules, but it disappears within a first few weeks. So not a harmful thing. None of those are harmful or bad in any way.
Moving on to the head, expected findings and normal variations. So remember, we just had to be pushed out through a birth canal, so what is going to help us with that, right? It's going to be those fontanels. We need to have a head that can be molded to get through the birth canal. So we have an anterior and a posterior fontanel at birth that are present and palpable and should be assessed when you are assessing the newborn. What we expect to find is that they should be symmetric. The baby should have a round head shape. That would be a normal finding. And the fontanel should be soft, flat, and open. So when we feel it, we should not feel any bulging, right? We should not feel anything that seems like it is inflamed or anything along those lines. The anterior fontanel, it is a diamond shape. It is larger and it's anterior, so it's going to be in the front. Our cool chicken here is how I remembered it all throughout nursing school is I like my diamonds large, front and center, right? So I just imagine that I have a very large diamond that I'm showing it off to somebody. I like to have it in the front. I like it to be big, and it's a diamond, so it's diamond-shaped versus the posterior fontanel is going to be triangular-shaped, and it is going to be smaller. So we're going to feel both of those when we are assessing the infant, make sure that we feel them, that they are open, they're flat, and they're soft.
Now, normal variations while molding is going to be a big one, that's going to be an elongated fetal head shape. My mom always jokes that I looked like a conehead when I was born if you've ever seen that movie. That's because of molding because I had to have my head squeezed through a birth canal. So it's going to be a little bit elongated. That is normal. Now, caput, oh God, don't make fun of me, succedaneum, succedaneum, so caput is what I'm going to call it. Caput is a type of soft tissue swelling that crosses the suture line, so remember, we have a suture right here going down our head. If the swelling crosses that suture line, it is a caput. Now we have a cool chicken here to help you remember. If it succeeds in crossing the suture line and it resolves sooner, then it's a caput succedaneum. But the way that I remembered it in nursing school, which is not on the card, is that if I wear a cap, the cap goes over my whole head, right? It crosses the suture line. That's how I remembered that, and it's going to resolve in about three days. Now, when we have a cephalohematoma, it's a similar idea. This is going to be a collection of blood between the skull and the periosteum, but it doesn't cross the suture line because it is constrained by the periosteum. So cephalohematoma is going to be on one side. It does not cross that suture line, and it's going to take a longer time to resolve. It can actually last for several months. So caput crosses the suture line like a cap. Cephalohematoma does not.
Okay. Lastly, we're talking about physical assessment here and expected findings for the face, neck, clavicle, umbilical cord, and hips. So face, we would expect them, the infant, to be able to blink, right, intact blink reflex. Their ears should be aligned with the outer canthi of the eyes. So if not, I mean, you can see like outer canthus of my eyes, my ears are right there. If they are lower set, that would be an abnormal finding, and that would also possibly be indicative of down syndrome. The mouth, we would expect that their membranes or mucous membranes are pink and moist and intact. Epstein pearls are listed here as a normal variation. These are small white cysts that can either be found on the gums or on the palate themselves. These are normal. They're okay. They will go away.
Now for neck and clavicles, we would expect full range of motion, no crepitus, right? Nothing should be crunchy under here. No tenderness. But remember, if we had birth trauma or something like that, we're going to want to assess those clavicles to make sure that we don't have a fracture or anything along those lines. That would not be good. Umbilical cord, we have a nice, cool chicken hint here for you that we think about baby Ava, A-V-A because we should have two arteries and one vein. So you should physically look at the umbilical cord and see, do we have two arteries and one vein? Sometimes cords and placentas can get sent off to pathology, either just as a routine part of that facility's policies, or if there is a concern that there was some sort of a problem, then we can send that off to pathology for further investigation.
Now remember, hips as well, we're looking to make sure head to toe, right, that everything looks within normal limits. So we would expect to have equal leg length, and we should have symmetrical gluteal and thigh creases, right? That's going to tell us that things are in line with the spinal column, no developmental dysplasia of the hip. So we would be checking Ortolani and Barlow maneuvers. We're checking for any clicks, thunks, any sort of indication that the hips are out of alignment. That would be abnormal if they are, so a normal finding would be negative Barlow and Ortolani tests.
I hope that review was helpful. I am going to ask you some quiz questions to test your knowledge of some key facts that I gave you in this video. Let me know in the comments how you do. Okay, so first question. The nurse is assessing a newborn 16 hours following birth and sees some jaundice in this newborn. Is this unexpected or an abnormal finding? Next, my question for you is that when assessing a newborn, the nurse notes an area of bluish pigmentation on the child's back that kind of looks like a bruise. What is the name of this finding, and is it a cause for concern? All right. When assessing a newborn, the nurse notes an area of swelling in the infant's head, and it's localized to the right side of the head. What is the name of this finding, and how long might it last? And lastly, how many arteries and how many veins should the newborn's umbilical cord contain?
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