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Initial and Subsequent Assessments

Immediately after birth, all infants should be briefly examined for major congenital abnormalities, signs of serious illness, or discrepancy between expected gestational age and weight for gestation. The number of nursing evaluations in the next few hours depends on anticipated problems and should focus on heart rate, respiratory rate and effort, temperature, skin perfusion, skin color, and neuromuscular activity. Observation of the first feeding, usually within 4 hours of birth, indicates any underlying difficulty with sucking and swallowing. If no abnormalities are noted at birth, further newborn observation should occur at least every 8 hours. Any abnormalities detected at any time warrant more frequent, thorough examinations and possible investigation and initial therapy.

All infants should undergo a detailed medical examination within 24 hours of birth to ensure that investigation, treatment, or preventive management, when indicated, is implemented as soon as possible and to answer any concerns that a parent may have. Reassurance to a mother (or guardian) shortly after delivery is immensely important regardless of maternal experience with deliveries.1 Further detailed examinations are necessary if any neonatal problems are detected; infants discharged early, before 24 hours, should be reexamined by 3 to 4 days of age.


The neonatal examination is best performed in an appropriately equipped, warm, draft-free room, preferably with the mother present; examining the infant under a servocontrolled radiant warmer is an alternative. Thorough hand-washing before and after handling each infant is essential to prevent the spread of pathogenic organisms. If possible, the infant’s mother or guardian should be present during the examination so the examiner may address any specific parental concerns or questions and observe parental-infant interaction. Observation of the infant’s appearance, posture, and state of consciousness should precede the formal aspects of palpation and auscultation. Presence of 1 anomaly suggests presence of another, since anomalies often coexist. Constellations of physical findings may indicate the presence of a syndrome. Evidence of trauma in one part of the baby should lead to a search for trauma in other areas. Signs of birth trauma are particularly common in large infants and in infants who underwent difficult deliveries such as breech or forceps delivery.

The obstetric history of the pregnancy and delivery may provide a clue or sign of possible neonatal problems. For example, polyhydramnios may signal bowel obstruction; oligohydramnios may signal renal anomalies and pulmonary insufficiency; small-for-gestational-age and postmature infants are suspect for hypoglycemia and polycythemia; and prolonged rupture of the membranes, maternal fever, and fetal tachycardia may signal neonatal sepsis. The neonatal consequences of intrauterine growth restriction, prematurity, multiple births, maternal diabetes, and meconium-stained amniotic fluid are discussed in detail in other sections.

Gestational Age and Size

The infant’s gestational age should be estimated and body size compared with appropriate normal standards.

There are several ways to estimate gestational age, including reliable ...

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