Physical Assessment of the Newborn by Ellen P. Tappero DNP RN NNP-BC Mary Ellen Honeyfield DNP RN NNP-BC

Author:Ellen P. Tappero, DNP, RN, NNP-BC,Mary Ellen Honeyfield, DNP, RN, NNP-BC
Language: eng
Format: epub
Publisher: Springer Publishing Company, Inc.
Published: 2016-07-15T04:00:00+00:00

TABLE 11-1 Distinguishing Seizure Activity from Jitteriness

Clinical finding

Seizure

Jitteriness

Abnormal gaze or eye movements

Yes

No

Stimulus sensitive

No

Yes

Ceases with passive flexion

No

Yes

Autonomic changes

Yes

No

Predominant movement

Clonic jerking

Tremor

Adapted from: Volpe JJ. 2008. Neurology of the Newborn, 5th ed. Philadelphia: Saunders, 214. Reprinted by permission.

The neonate’s state should be noted both before and during the examination, which optimally is performed with the neonate in the quiet alert state. Timing the examination for 30 minutes to one hour before a feeding may increase the chances of the neonate being in this state. Prior to 28 weeks gestation, it is difficult to identify periods of wakefulness. Stimulation may result in eye opening and apparent alerting for short periods. At approximately 28 weeks gestation, there is an increase in the level of alertness, and both stimulated and spontaneous alerting can be seen. The premature neonate has longer sleep cycles than the term neonate. Sleep-wake cycles are more apparent by 32 weeks gestation, and stimulation is usually not necessary to arouse and alert the neonate. By 37 weeks, increased alertness can be readily observed.

EXAMINATION OF THE HEAD

The status of the fontanels and sutures should be evaluated initially by gentle palpation in the non-crying neonate (Chapter 5). The examiner palpates the fontanel and sutures to determine size and to assess if they are soft and flat or full and bulging. A full or bulging fontanel with widened sutures may indicate increased intracranial pressure and hydrocephalus. Widening of the sutures alone, with a normal anterior fontanel, may be caused by abnormal ossification seen with intrauterine growth restriction. The head is palpated for other abnormalities, such as cephalhematoma and nondisplaceable sutures.

Head circumference is measured, plotted on a growth chart, and the percentile determined based on gestational age. A neonate with a head circumference greater than the 90th percentile for gestational age and weight, and height below the 90th percentile may have hydrocephaly, macrocephaly, or hydranencephaly. The skull configuration in hydrocephalus is frequently globular. Posterior ballooning of the skull is seen with hydrocephalus caused by Dandy-Walker syndrome, which consists of congenital agenesis of the foramen of Magendie and Luschka with dilation of the fourth ventricle. Abnormalities in skull configuration are also seen in some neonates with craniosynostosis. When a large head circumference and percentile for gestational age are identified, transillumination of the skull can be helpful. In a dark room and after the examiner’s eyes have adapted to the reduced light, a rubber-cuffed flashlight or other transillumination device is applied firmly to the skull (see Figure 1-2). A glow of more than 2 cm around the rubber cuff of the flashlight is abnormal and reflects fluid accumulation.

Neonates with small head circumferences (less than the tenth percentile for gestational age) may have microcephaly caused by a chromosomal abnormality, or maternal drug and alcohol intake. Also, intrauterine infection may be present in microcephaly or the small-for-gestational-age neonate. Cytomegalovirus infection or other TORCH infections should be considered as causative. Marked molding of the head following birth may give the erroneous impression of microcephaly, especially when the shape of the head is conical.

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