A prenatal history is imperative to the comprehensive care of each newborn and should cover the maternal sequelae, family history, and fetal care history [3]. Maternal history consists of information concerning past pregnancies, including complications, and specifics of labor and maternal illness, including infections and the use of alcohol or drugs [3]. It should also elicit information regarding the current pregnancy, such as the quality and quantity of prenatal care, current laboratory values (including blood type and Rh factor and the results of standard group B streptococcus screening), and the presence of any significant risk factors to the fetus. Obtaining a family history involves inquiring regarding past illnesses, genetic issues, and physiologic problems of parents and siblings [3]. The neonatal history encompasses factors such as vital signs, Apgar scores, required stabilization interventions, and the newborn's general appearance and reaction to the environment [3].

Gestational diabetes affects up to 9.2% of all pregnancies [12,13]. Factors that place women at higher risk for developing gestational diabetes include age of 25 years or older, obesity, and a family history of type 2 diabetes [4,14]. The infant of a mother with diabetes, regardless of whether the cause is gestational diabetes or pre-existing disease, is affected in a multitude of ways. The effects are more pronounced in "brittle" cases. Fetuses that are continuously exposed to high blood glucose levels will produce more insulin in response, leading to excessive fetal growth and infants who are large for gestational age (i.e., macrosomia) [1,14]. This in turn can place them at higher risk for birth trauma and shoulder dystocia [4]. In the neonatal period, infants of mothers with diabetes are also more likely to experience hypoglycemia that results from the precipitous drop in available blood sugar while they continue to produce excessive amounts of insulin. This can lead to serious neurologic damage with complications including developmental delay, heart failure, and seizures [13,14,15]. Infants of mothers with diabetes are also at higher risk for neonatal jaundice, and women with diabetes are at higher risk for developing pre-eclampsia [4,14]. These infants are also more likely to be obese and develop type 2 diabetes as adults [13].

A thorough assessment of the placenta at the time of delivery may assist with age determination and present significant diagnostic information [3]. The placenta should be assessed for size, color, odor, and the presence and number of membranes [3,25].

All nurses should be familiar with the ABCs of resuscitation: airway, breathing, and circulation. Because newborns are wet when they are born, they can suffer rapid heat loss if a warm environment is not maintained [28]. Therefore, it is critical to maintain a warm, or thermoneutral, environment for the infant throughout the first hours and days of life. This can be accomplished by placing the infant on the mother's abdomen, with warm blankets placed over them both to maintain body heat. Alternatively, if the need for further intervention is anticipated, or if the caregiver prefers, the infant should be placed on a preheated radiant warmer.

All nurses should be familiar with the ABCs of resuscitation: airway, breathing, and circulation. Because newborns are wet when they are born, they can suffer rapid heat loss if a warm environment is not maintained [28]. Therefore, it is critical to maintain a warm, or thermoneutral, environment for the infant throughout the first hours and days of life. This can be accomplished by placing the infant on the mother's abdomen, with warm blankets placed over them both to maintain body heat. Alternatively, if the need for further intervention is anticipated, or if the caregiver prefers, the infant should be placed on a preheated radiant warmer.

In 1953, an anesthesiologist named Virginia Apgar designed a tool for evaluating newborn infants [35]. The Apgar scores grade the infant's response to extrauterine life in five categories [36]:

Heart rate

Respiratory effort

Muscle tone

Reflex irritability

Color

Color can be assessed by noting the color of mucous membranes, the trunk, and the soles of the feet. The infant should be pink and not dusky. An infant who is completely pink, including the hands and feet, would be awarded 2 points in this category. An infant that is pink but is acrocyanotic (i.e., has blue hands and/or feet) would receive 1 point. An infant that is blue, gray, or dusky would receive zero points [35,36].

Classification of weight may be used independent of gestational age. Extremely low birth weight infants weigh less than 1,000 grams, very low birth weight newborns weigh less than 1,500 grams, and low birth weight newborns weigh less than 2,500 grams[51]. Normal weight in a term newborn ranges from 2,500 to 4,000 grams[52,53].

The skin should be evaluated next. There are seven subclassifications in the skin category. The extremely premature infant has transparent, friable skin and woulsd be awarded -1 points. The postmature infant presents with leathery, tough, cracked skin and would receive 5 points. Infant A has a fine rash. There appears to be some peeling, with few veins visible on the abdomen. She is awarded 2 points for her skin maturity.

Finally, the points for each category are added to give an estimated gestational age. In our example, Infant A received 15 points in the neuromuscular maturity area and 15 points in the physical maturity section. This is a grand total of 30 points, making her approximately 36 weeks' gestation.

Neonatal hyperbilirubinemia, or jaundice, is the yellowish discoloration of an infant's skin and sclera caused by a buildup of the bile pigment bilirubin. Hyperbilirubinemia that is noted in the first 24 hours of life is considered pathologic and should be treated appropriately [65]. Hyperbilirubinemia is a normal variation to a certain degree, and most infants will show some signs during the first week of life [65]. The severity and diagnosis of hyperbilirubinemia is dependent on the bilirubin level at a certain newborn age as well as the presence of risk factors [65,66].

Newborns become jaundiced for two main reasons: immaturity of the liver and/or the excessive amount of fetal hemoglobin that is required in utero. The liver is thought to be one of the last organs to fully mature; therefore, even the full-term infant may be considered to have an immature liver. The liver is where bilirubin, a byproduct of hemoglobin metabolism, is processed, and the immature organ may not be able to keep up with the increased demand that occurs shortly after birth. The increased demand is caused by the breakdown of fetal hemoglobin.

In utero, fetuses are exposed to a much lower partial oxygen pressure (PO₂) than that of the air they begin to breathe as soon as they are born. For this reason, they are in need of a much higher amount of fetal hemoglobin than is necessary after they are born. Fetal hemoglobin has unique characteristics. It has less oxygen carrying capacity, though it does have a greater affinity for the oxygen molecule. Because of the strong oxygen affinity, the oxygen does not unload until the tissue oxygen levels in an infant are lower than they would be in an adult. After they are born, infants begin to rapidly break down the excess hemoglobin to adjust to the much higher PO₂ of the air. When fetal hemoglobin is broken down, the heme is converted to biliverdin and then to unconjugated bilirubin. When the unconjugated bilirubin level exceeds normal, there becomes an increased chance of it depositing in the basal ganglia. Deposition of unconjugated bilirubin in the brain is known as kernicterus, a chronic and permanent form of hyperbilirubinemia that can be life-threatening [66].

In utero, fetuses are exposed to a much lower partial oxygen pressure (PO₂) than that of the air they begin to breathe as soon as they are born. For this reason, they are in need of a much higher amount of fetal hemoglobin than is necessary after they are born. Fetal hemoglobin has unique characteristics. It has less oxygen carrying capacity, though it does have a greater affinity for the oxygen molecule. Because of the strong oxygen affinity, the oxygen does not unload until the tissue oxygen levels in an infant are lower than they would be in an adult. After they are born, infants begin to rapidly break down the excess hemoglobin to adjust to the much higher PO₂ of the air. When fetal hemoglobin is broken down, the heme is converted to biliverdin and then to unconjugated bilirubin. When the unconjugated bilirubin level exceeds normal, there becomes an increased chance of it depositing in the basal ganglia. Deposition of unconjugated bilirubin in the brain is known as kernicterus, a chronic and permanent form of hyperbilirubinemia that can be life-threatening [66].

Also referred to as strawberry mark, nevus vascularis, capillary hemangioma, or hemangioma simplex, strawberry hemangiomas consist of newly formed capillaries occupying both the dermal and subdermal layers. Strawberry marks are typically raised, sharply demarcated, and bright red. However, these lesions may also present as a patch of pale skin or may not be visible at all [67]. Hemangiomas may be present at birth but most often appear in the first several months of life. They occur most often on the neck and face [68]. Generally, no intervention is required, though many parents will need reassurance that the lesion will involute spontaneously in most cases [67,68]. It is possible for these lesions to compress the eyes, airway, or vital organs, in which case the infant should be referred immediately for treatment, usually with steroid injections or laser therapy [67].

Nevus simplex, also referred to as stork bites, angel kisses, or salmon patches, appear in 30% to 50% of all newborns [67]. Nevus simplex is generally found at the nape of the neck, but may be also found on the face and scalp. It appears pink in color, blanches with pressure, and is commonly bilateral [67,68]. It has no clinical significance and fades quickly, often having disappeared entirely by 18 months of age [70].

A normal fontanelle should feel soft, yet spongy, and very slightly depressed [80]. A bulging fontanelle appears as a convex shape that feels firm but not spongy. The presence of a bulging fontanelle is indicative of increased intracranial pressure (ICP). Although there are numerous causes, the most common are hydrocephalus, trauma, intracranial hemorrhage, and infections, such as meningitis and encephalitis [74,80]. Accurate diagnosis of the cause of increased ICP may require imaging techniques, such as magnetic resonance imaging, computed tomography, and/or cranial ultrasound [74,79,81]. Crying, lying down, or vomiting can also cause slight bulging of the fontanelle. If the fontanelle returns to normal when the infant is returned to an upright position, it not considered a true bulging fontanelle.

Warning signs of the neurologic assessment, which would warrant further investigation and/or immediate intervention, include [35,92]:

Lack of reflex/response to stimuli

Hypertonic or hypotonic position

General lethargy

Pupillary changes

Warning signs of the respiratory assessment, which would warrant further investigation and/or immediate intervention, include [33,35,118]:

Respiration rate less than 30 or greater than 60 breaths per minute. In some cases, respiratory rates up to 70 breaths per minute in the first few hours of life are acceptable. When assessing rate, a full minute count should be taken to compensate for irregularities in pattern.

Apnea lasting 20 seconds or longer

Presence of central cyanosis. Acrocyanosis may be a normal finding in the newborn, but central cyanosis, or the blue or gray coloring of the mucous membranes, trunk, or entire body, is never a normal finding and requires immediate intervention.

RDS presents either at birth or within the first eight hours of life [120]. If symptoms occur after the first eight hours, then it is unlikely that RDS is the cause. The most common signs of RDS are [120]:

Tachypnea

Dyspnea

Grunting with expiration

Intercostal retractions with inspiration

Nasal flaring

Increasing cyanosis

Meconium aspiration syndrome (MAS) is another cause of respiratory distress in newborns and occurs in approximately 5% of those born with meconium-stained amniotic fluid [127,128]. It is caused by the aspiration of meconium-stained amniotic fluid into the trachea. Meconium staining may be noted by assessing the infant's skin, nails, and umbilical cord and can affect the infant's Apgar score [35]. Presence of meconium may clue the practitioner to assess for tachypnea, hypoxia, and hyper- or hypoventilation [86]. The presence of rales, rhonchi, wheezing, wet sounds with possible retractions, and labored breathing are possible, depending upon the extent of aspiration. Risk factors for MAS include [128]:

Fetal distress, long labor, or difficult delivery

Maternal diabetes

Maternal hypertension

Low oxygen supply to the infant in utero

Meconium aspiration is associated with asphyxia, but routine intubation and intrapartum suctioning are no longer recommended, regardless of the infant's activity level [127]. Gently clearing the nose and mouth of meconium with a bulb syringe may be warranted. A neonatal advanced life support team should be notified and available to treat a newborn with meconium-stained amniotic fluid [127]. Other treatments for MAS include oxygen therapy, mechanical ventilation, fluid support, a warmer to control temperature, and antibiotics [128,129].

The fetal cardiovascular system is markedly different from that of the newborn. Because the fetus does not rely upon its lungs for oxygenation, very little blood flows through the pulmonary vasculature. Fetal circulation begins with oxygenated blood traveling to the fetus through the umbilical vein. Note the unusual circumstance of a vein carrying richly oxygenated blood. The blood enters the fetus at the site of the umbilicus and divides into two branches. One branch carries blood to the fetal liver, while the other, larger branch carries blood through the ductus venosus into the fetal vena cava [33]. The oxygen-rich blood then travels to the fetal heart through the right atrium. In an adult, the blood passes into the right ventricle for distribution into the pulmonary vasculature, which would then oxygenate the blood. Because the blood in the fetus is already oxygenated, the majority then passes through the foramen ovale to the left atrium. A small amount of blood does pass into the right ventricle, which pumps the blood into the pulmonary artery to oxygenate the lung tissue. However, the majority of this blood also passes through another duct, the ductus arteriosus, into the aorta for distribution to the body [33]. The deoxygenated blood then leaves the fetus via two umbilical arteries for nutrient and gas exchange in the intervillous spaces of the placenta.

It takes time for the fetal right ventricular muscle to remodel itself into the lesser pump side and decrease work [114]. Though the left side of the heart is functioning as in an adult, the muscle mass may not achieve complete dominance over the right ventricle until the sixth month of life [114].

Murmurs occur as blood moves through a highly turbulent area in the heart. Heart murmurs are very common in newborns as their cardiopulmonary systems adjust to extrauterine life [92,136]. These benign murmurs in newborns are usually transient in nature and caused by the foramen ovale not being closed completely. Murmurs are usually benign and not necessarily indicative of heart disease [85]. They generally resolve spontaneously.

The tetralogy of Fallot is the most common cyanotic CHD, occurring in approximately 1 in every 2,500 newborns, although it may not be evident as early as other defects [152,153]. It is characterized by four components: pulmonary stenosis, overriding aorta, right ventricular hypertrophy, and VSD [152,153]. Tetralogy of Fallot has been associated with the same conditions as TGA; however, chromosomal disorders are also common in this population [152].

Assessing stool quantity and quality is an important part of the gastrointestinal assessment. Meconium should be passed within 24 hours [75]. If the infant has not passed meconium within the first 24 hours, a further assessment is warranted to rule out ileus or obstruction. By the second or third day, the infant should begin to have transitional stool, which is green or yellowish and may have a seedy appearance. Within several days to a week, breastfed infants' stools take on the appearance of mustard.

Congenital diaphragmatic hernia is an anomaly in which the muscular or tendinous parts of the diaphragm do not develop in the fetus and, consequently, abdominal contents protrude into the chest cavity [75]. This intrusion affects the development of other organs, mainly the lungs. It is important to note that congenital diaphragmatic hernia is not readily detectable through inspection and palpation. Signs of diaphragmatic hernia include a flat or scaphoid abdomen, barrel chest, difficult intubation, cyanosis, tachypnea, tachycardia, and bowel sounds that may be auscultated in the thoracic cavity [33,164]. Mortality rates and prognosis are generally poor and have been related to the presence of associated anomalies, prenatal diagnosis, prematurity, low birth weight, and early pneumothorax. Pulmonary hypertension and pulmonary hypoplasia are the recognized pathophysiologic cornerstones [164,165].

Observe for color, odor, frequency, and amount of void. Failure to void with in the first 24 hours is considered a warning sign and warrants further evaluation. The normal urine output for an infant is at least 1–2 cc/kg/hour. Output may be as high as 4 cc/kg/hour in the first few days of life [50]. Urine output should be made with a stream of urine under an adequate amount of pressure. Urine is normally straw colored, though variations in color do exist, ranging from clear to amber, and may or may not have sediment.

The scrotum should appear loose and pendulous, and each side should be manually assessed to determine the presence of testes. The testes usually descend in the third trimester and are approximately 1 cm in diameter at birth [3,91]. Containing the testes with the index finger and the thumb of one hand at the upper part of the scrotal sac may prevent retraction of the testes during assessment. Undescended testes may or may not be palpable in the inguinal canal. If the testicle cannot be pushed into the scrotum manually, then it is considered undescended. Bilateral undescended testes, micropenis, and/or bifid scrotum should prompt further evaluation [185]. The appearance of rugae may assist in providing information concerning the maturity of the infant. Absence of rugae may be a sign of prematurity [3,91]. Edema of the genital area following birth may be present, especially in breech births, but should resolve in a few days. Hydrocele is the collection of fluid around the testes in the scrotum and a relatively common finding. It can appear quite large and feel tight; diagnosis is made by transilluminating the scrotum. Hydrocele generally resolves on its own and requires no intervention.

The arms and hands should be evaluated for symmetry, webbing, range of motion, and the number of digits [33]. Fingernails are generally long and in need of trimming in the term newborn. The palms should be examined for the presence of a single palmar crease (previously referred to as a "simian" crease) that extends all the way across the hand. A single palmar crease is associated with Down syndrome [177].

Formerly known as congenital hip dislocation, developmental dysplasia of the hip (DDH) is an uncommon finding. However, according to the AAP, ease and efficacy of treatment is directly influenced by how early this condition is diagnosed [179,180]. Diagnosis of DDH is based upon the presence of unstable, subluxated, or dislocated hips or acetabula malformations. The majority (76%) of DDH cases occur in female infants. Other conditions that predispose infants to DDH include [179,180]:

Breech birth

Maternal oligohydramnios

Family history