1. General Appearance

• Body Posture: flexion.
• Respirations: unlabored, rise and fall symmetrically, slight irregularity, clear.
• Color: acrocyanosis (bluish hands and feet).

1. Head

• Hair Strands
• Lacerations/bruises: from trauma of birth.
• Cephalhematoma: a mass composed of clotted blood, located between the periosteum and the skull of a newborn; the swelling is confined between suture lines and usually is unilateral.
• Caput Succedaneum: diffuse edema of the fetal scalp that crosses the suture lines; head compression against the cervix impedes venous return, forcing serum into the interstitial tissues; swelling reabsorbs within 1-3 days.
• Fontanel: Anterior fontanelà diamond shaped, depressed = dehydration, bulging = increased intercranial pressure, closes in 12-18 months. Posterior fontanelà triagnle shaped, 2-3 months closes.
• Molding: cone shaped cranium after vaginal birth.
• Head circumference: 31-38cm, done at birth and every office visit.

1. Ears: developed same time as kidney. If ther is a problem with ears, then there is a problem with the kidneys.

• Cartilage in Pinna: firm.
• Placement of Ears: low set could indicate chromosomal abnormalities.

1. Eyes

• Spacing of Eyes: the distance between the inner canthus of each eye is = to the width of the eye itself.
• Conjunctival Hemorrhage: occur from pressure during birth.
• Opacity of pupils

1. Nose:

• Milia: white pinhead-size, keratin-filled cyst; in newborn, milia occur on the face and, less frequently, on the trunk, and usually disappear within several weeks.
• Choanal Atresia: A congenital occlusion of the passage between the nose and pharynx by a bony or membranous structure.

1. Mouth:

• Thrush plaques
• Suck Reflex: well developed.
• Hard Palate: palpate with gloved finger; should be intact.
• Epstein’s Pearls: whitish-yellow accumulation of epithelial cells, or retention cysts, on the hard palate; they are harmless and disappear within a few week. If they are loose, they are removed because they pose a risk for aspiration.
• Frenulum: a small fold that attaches the lower side of the tongue to the floor of the buccual cavity. In neonates, it may be tight.

7. Facial Symmetry: is there any drooping.

8. Neck: symmetrical with full ROM.

• Clavicle: should be symmetrical; if has crepitation, this indicates a clavicle fracture.

9. Skin:

• Vernix caseosa: whitish-yellow, greasy textured, cheese like substance that covers the fetus in utero.
• Lanugo: soft, down like growth of hair commonly seen on the shoulders and back of the normal newborn.
• Erythema toxicum: "newborn rash", appears as firm white or whitish-yellow papules or pustules varying in size from 1-3mm; widespread over the body but does not appear on the palms of the hands or the soles of the feet.
• Icterus Neonatorum: physiologic jaundice, appears in many newborns on the second or third day after birth.
• Mongolian spots: slate-gray discolorations present at birth and most frequently noted on the buttocks or lower portion of the back of the newborn.
• Nevus Flammeus: type of hemangioma, also known at "port wine stain"; these birthmarks are not elevated, are red to purple, and generally appear on the face.
• Telangiectatic nevi: commonly referred to as "stork bites: are temporary, superficial vascular lesions formed by dilation of a group of small blood vessels; may appear as fine red lines and are sometimes seen at the nape of the neck, upper eyelid or upper lip.

9. Extremities:

• Arms: movement and flexion.
• Hands: number of digits present; finger grasp; Simian crease (commonly seen in Down syndrome), normally the palm of the hand at birth contains several flexion creases.
• Legs: signs of congenital hip dislocation.
• Capillary refill

9. Chest: measure at level of nipples; should be 3cm less than head.

• Symmetry of chest
• Breast: areolae are stippled, 1cm diameter.
• Heart sounds: between 4^th and 5^th intercostal space for 1 full minute; rate, rhythm, abnormal sounds.
• "Witches Milk": white discharge when palpated. Caused by influence of maternal estrogen.

9. Abdomen:

• Contour of Abdomen: slightly protrudes and symmetrical.
• Bowel sounds: may be heard 15minutes to 2 hours after birth; assess after heart and lungs have been auscultated.
• Diastasis Recti: a separation of the two halves of the rectus abdominis muscles in the midline at the linea alba.
• Vessels on skin of Abdomen
• Umbilical Cord: look for drainage or foul odor; falls off within 10-14 days.

9. Femoral Pulses: should be equal.
10. Genitalia:

• Male: scrotumà look for rugae; testesà make sure descended; meatus openingà epispadias (congenital opening of the urethra on the dorsum of the penis) or hypospadias (congenital opening of the urethra upon the undersurface of the penis). Smegma à collection of cheesy like secretions found under the foreskin of the penis in an uncercumcised neonate.
• Female: labia minora and majora; look for vaginal and urethral opening; pseudomenstruation à whitish or bloody discharge caused by influence of maternal estrogen.
• Anus should be patent.

9. Spinal Canal: should be straight and midline.

• Sacral dimple
• Hair tuft
• Occult spinal bifida

9. Reflexes: indicate normal CNS.

• Hand grasp: hand around finger.
• Rooting reflex: stroke side of cheek and neonate turns head.
• Sucking reflex: well developed.
• Stepping reflex: steps like trying to walk.
• Tonic neck/fencing reflex: head to side, leg and arm extend of that side and leg and arm flex on other side.
• Moro relfex: abduction and extension of arms and legs in response to being startled.
• Babinski: should fan.

9. Neurologic Considerations:

• Recoil of arms and legs: bring arms and legs down and observe how they recoil back.
• Angles of wrist, feet, popliteal, heel to ear.
• Scarf sign: note where the elbow is in relation to midline.
• Head lag.
• Ventral suspension.