NR602 – Primary Care of the Childbearing & Childrearing Family
WEEK 2 COMPREHENSIVE STUDY GUIDE
Pediatric Well-Child Assessment, Growth, Development, and Congenital/Inherited Disorders
Midterm Exam Coverage: Weeks 1–4 | 75 Questions | Closed Book | ExamSoft
1. NEWBORN ASSESSMENT
1.1 The Neonatal Period
• Neonatal period = first 28 days of extrauterine life
• At birth, the newborn undergoes extraordinary biochemical and physiologic changes — the
placenta no longer provides metabolic functions
• Key transitions: foramen ovale and ductus arteriosus close; lungs begin gas exchange; GI tract
absorbs nutrients; renal system excretes wastes; liver metabolizes toxins
1.2 APGAR Score — Immediate Assessment at 1 and 5 Minutes
APGAR = Activity, Pulse, Grimace, Appearance, Respiration. Each scored 0–2, max 10.
APGAR Score Clinical Status Management
8–10 Vigorous, pink, crying Warming, drying, gentle
stimulation; brief O2 if needed
5–7 Cyanotic, slow/irregular respirations, Bag-and-mask ventilation; observe
good tone/reflexes closely
4 or less Limp, pale or blue, apneic, slow HR Maximal resuscitation: bag/mask,
chest compressions, IV volume,
drugs
• 1-minute score: reflects transition to extrauterine life
• 5-minute score: indication of how well resuscitation succeeded
• APGAR score is useful only when COMBINED with fetal status, umbilical cord/scalp pH, organ
injury, or seizures for predicting long-term outcomes
• Decision to resuscitate is made by quick assessment BEFORE 1 minute: heart rate, color,
respiratory rate
1.3 Gestational Age Classification
• Maturational assessment done within 2 hours of birth (Ballard Score)
• LGA (Large for Gestational Age): weight above 90th percentile — risk for hypoglycemia
• AGA (Appropriate for Gestational Age): weight between 10th and 90th percentile
• SGA (Small for Gestational Age): weight below 10th percentile — risk for hypoglycemia,
growth delays
• Gestational age correlates with maturity of all organ systems
1.4 Normal Newborn Vital Signs and Measurements
Parameter Normal Range
Temperature 97.7°F – 99.3°F (36.5°C – 37.4°C) in open crib
,Heart Rate 100–190 bpm
Respiratory Rate 30–60 breaths/min
Weight loss Up to 10% in first 2–3 days is NORMAL
Head circumference ~33 cm; ~2 cm larger than chest circumference
Systolic BP >96 mmHg considered significant hypertension in newborn
Anterior fontanel ~2–3 cm diameter
Posterior fontanel ~1 cm diameter
1.5 Newborn Physical Examination Findings (System-by-System)
• Skin: Lanugo (fine hair), vernix (white waxy coating), dry/cracked skin are normal. Milia = firm
white pearly papules on face (intraoral = Epstein pearls) — resolve spontaneously. Erythema
toxicum = yellow-white papules with erythematous flare at 24-48 hrs in up to 50% of newborns
— NO treatment needed.
• Head: Molding, overriding sutures common with vaginal delivery. Anterior fontanel ~2-3 cm,
posterior ~1 cm. Bulging = increased ICP; sunken = dehydration.
• Eyes: Intermittent disconjugate gaze (uncoordinated eye movements) is NORMAL in first weeks
— resolves by 6 months. Check RED REFLEX bilaterally (absent = cataract or retinoblastoma).
Conjunctivae may be reddened from ocular prophylaxis agent.
• Umbilical Cord: Normal = 2 arteries + 1 vein (2 thick, 1 thin). Single umbilical artery (SUA) =
associated with congenital cardiac or renal anomalies. Cord falls off at 10–14 days. Leave to air
dry; avoid alcohol. Foul-smelling discharge or expanding erythema = evaluate immediately for
sepsis.
• Heart: PMI at 4th left intercostal space. HR 100-190 bpm. Murmurs common in newborn —
many resolve. Brachial/radial pulses compared to femoral/dorsalis pedis for symmetry.
• Abdomen: Slightly protuberant, soft, smooth with respirations. Liver palpable 1-2 cm below
right costal margin. First stool (meconium) should pass in first 24–48 hours.
• Male Genitalia: Urethral opening at tip of penis. Foreskin fully developed. Hydrocele
(transilluminates) is normal unless associated with hernia or lasts >12 months.
• Female Genitalia: Labia majora cover labia minora. White vaginal discharge normal. Blood-
tinged fluid by day 2-3 is normal (maternal hormones).
• Hips: Ortolani and Barlow maneuvers assess for developmental hip dysplasia.
• Neurologic Reflexes: Rooting, suck/swallow, palmar grasp, Moro (startle), stepping, placing,
Galant (truncal incurvation), asymmetric tonic neck. Ankle clonus 3–4 beats is normal.
1.6 Newborn Screening
• ALL states require newborn screening for genetic and metabolic disorders — specific panel
varies by state (RUSP = Recommended Uniform Screening Panel)
• Screen before discharge; if done before 24 hours, REPEAT by 14 days old
• Includes: PKU, congenital hypothyroidism, sickle cell, hearing, CCHD, bilirubin, metabolic
disorders
• Congenital Hypothyroidism (CH): Screen within first 4 days of life. CH is the most common
cause of PREVENTABLE mental retardation. Untreated → irreversible brain damage.
• PKU: Deficiency of phenylalanine hydroxylase → phenylalanine accumulates → intellectual
disability if untreated.
• CCHD screening: Pulse oximetry prior to discharge.
, • Hearing screening: Universal by 1 month old — OAE or auditory brainstem response (ABR)
prior to discharge. Repeat if missed.
• Bilirubin: Transcutaneous or serum, prior to discharge.
1.7 Newborn Eye Screening
• Topical ocular prophylaxis (erythromycin ointment) of ALL newborns to prevent ophthalmia
neonatorum (gonorrheal eye infection)
• Red reflex check bilaterally — absent or abnormal = refer immediately for ophthalmology
evaluation (suspect cataract, glaucoma, retinoblastoma)
• Disconjugate gaze: normal in newborns, improving by 2–4 months, resolving by 6 months
1.8 Early Discharge Guidelines
• Hospital stay: minimum 48 hours for vaginal delivery, 96 hours for C-section (Newborns' and
Mothers' Health Protection Act of 1996)
• Follow-up care should occur within 48–72 hours of discharge — assess weight, hydration,
jaundice, feeding, bonding, outstanding labs
• Before discharge: HepB #1, Vitamin K IM, erythromycin eye ointment, newborn screening,
CCHD screening, hearing screening
• Refer to WIC program as appropriate
1.9 Common Neonatal Conditions — Newborn Digestive System and Nutrition
• Jaundice/Hyperbilirubinemia: Physiologic jaundice appears day 2-3, peaks day 3-5, resolves
by 2 weeks. Asian descent: peaks day 4-5. Pathologic = appears within 24 hours, rises rapidly,
persists. Management: phototherapy based on bilirubin level and gestational age.
• Breastfeeding: Recommended exclusively for first 6 months. Breastfed infants need
supplemental Vitamin D 400 IU/day until consuming 32 oz formula/day or fortified milk.
• Cord care: Air dry; diaper below cord. Separation at 10–14 days. Slight bloody discharge 1-2
days after separation is normal. NO alcohol application.
• Colic: Crying >3 hrs/day, >3 days/week, >3 weeks in infants 1–4 months. NORMAL
developmental behavior. PURPLE acronym: Peak/Unexpected/Resists soothing/Pain-like
face/Long-lasting/Evening. No evidence for formula changes or medications.
2. WELL-CHILD VISITS & ANTICIPATORY GUIDANCE
2.1 AAP Well-Child Visit Schedule
Visits are recommended at: birth, 3-5 days, 4 weeks, 2, 4, 6, 9, 12, 15, 18, and 24 months, annually up
to age 6, then every 2 years through adolescence.
Age Group Key Measurements Key Screenings
Newborn / 2-4 Length/weight, head Hearing, vision risk assessment, lead
Months circumference, developmental risk assessment
surveillance, behavioral
assessment, maternal depression
screening
4–6 Months Same as above + immunizations Lead risk assessment, developmental
milestones
9–12 Months Length/weight, head Vision risk, hearing risk, lead risk,
WEEK 2 COMPREHENSIVE STUDY GUIDE
Pediatric Well-Child Assessment, Growth, Development, and Congenital/Inherited Disorders
Midterm Exam Coverage: Weeks 1–4 | 75 Questions | Closed Book | ExamSoft
1. NEWBORN ASSESSMENT
1.1 The Neonatal Period
• Neonatal period = first 28 days of extrauterine life
• At birth, the newborn undergoes extraordinary biochemical and physiologic changes — the
placenta no longer provides metabolic functions
• Key transitions: foramen ovale and ductus arteriosus close; lungs begin gas exchange; GI tract
absorbs nutrients; renal system excretes wastes; liver metabolizes toxins
1.2 APGAR Score — Immediate Assessment at 1 and 5 Minutes
APGAR = Activity, Pulse, Grimace, Appearance, Respiration. Each scored 0–2, max 10.
APGAR Score Clinical Status Management
8–10 Vigorous, pink, crying Warming, drying, gentle
stimulation; brief O2 if needed
5–7 Cyanotic, slow/irregular respirations, Bag-and-mask ventilation; observe
good tone/reflexes closely
4 or less Limp, pale or blue, apneic, slow HR Maximal resuscitation: bag/mask,
chest compressions, IV volume,
drugs
• 1-minute score: reflects transition to extrauterine life
• 5-minute score: indication of how well resuscitation succeeded
• APGAR score is useful only when COMBINED with fetal status, umbilical cord/scalp pH, organ
injury, or seizures for predicting long-term outcomes
• Decision to resuscitate is made by quick assessment BEFORE 1 minute: heart rate, color,
respiratory rate
1.3 Gestational Age Classification
• Maturational assessment done within 2 hours of birth (Ballard Score)
• LGA (Large for Gestational Age): weight above 90th percentile — risk for hypoglycemia
• AGA (Appropriate for Gestational Age): weight between 10th and 90th percentile
• SGA (Small for Gestational Age): weight below 10th percentile — risk for hypoglycemia,
growth delays
• Gestational age correlates with maturity of all organ systems
1.4 Normal Newborn Vital Signs and Measurements
Parameter Normal Range
Temperature 97.7°F – 99.3°F (36.5°C – 37.4°C) in open crib
,Heart Rate 100–190 bpm
Respiratory Rate 30–60 breaths/min
Weight loss Up to 10% in first 2–3 days is NORMAL
Head circumference ~33 cm; ~2 cm larger than chest circumference
Systolic BP >96 mmHg considered significant hypertension in newborn
Anterior fontanel ~2–3 cm diameter
Posterior fontanel ~1 cm diameter
1.5 Newborn Physical Examination Findings (System-by-System)
• Skin: Lanugo (fine hair), vernix (white waxy coating), dry/cracked skin are normal. Milia = firm
white pearly papules on face (intraoral = Epstein pearls) — resolve spontaneously. Erythema
toxicum = yellow-white papules with erythematous flare at 24-48 hrs in up to 50% of newborns
— NO treatment needed.
• Head: Molding, overriding sutures common with vaginal delivery. Anterior fontanel ~2-3 cm,
posterior ~1 cm. Bulging = increased ICP; sunken = dehydration.
• Eyes: Intermittent disconjugate gaze (uncoordinated eye movements) is NORMAL in first weeks
— resolves by 6 months. Check RED REFLEX bilaterally (absent = cataract or retinoblastoma).
Conjunctivae may be reddened from ocular prophylaxis agent.
• Umbilical Cord: Normal = 2 arteries + 1 vein (2 thick, 1 thin). Single umbilical artery (SUA) =
associated with congenital cardiac or renal anomalies. Cord falls off at 10–14 days. Leave to air
dry; avoid alcohol. Foul-smelling discharge or expanding erythema = evaluate immediately for
sepsis.
• Heart: PMI at 4th left intercostal space. HR 100-190 bpm. Murmurs common in newborn —
many resolve. Brachial/radial pulses compared to femoral/dorsalis pedis for symmetry.
• Abdomen: Slightly protuberant, soft, smooth with respirations. Liver palpable 1-2 cm below
right costal margin. First stool (meconium) should pass in first 24–48 hours.
• Male Genitalia: Urethral opening at tip of penis. Foreskin fully developed. Hydrocele
(transilluminates) is normal unless associated with hernia or lasts >12 months.
• Female Genitalia: Labia majora cover labia minora. White vaginal discharge normal. Blood-
tinged fluid by day 2-3 is normal (maternal hormones).
• Hips: Ortolani and Barlow maneuvers assess for developmental hip dysplasia.
• Neurologic Reflexes: Rooting, suck/swallow, palmar grasp, Moro (startle), stepping, placing,
Galant (truncal incurvation), asymmetric tonic neck. Ankle clonus 3–4 beats is normal.
1.6 Newborn Screening
• ALL states require newborn screening for genetic and metabolic disorders — specific panel
varies by state (RUSP = Recommended Uniform Screening Panel)
• Screen before discharge; if done before 24 hours, REPEAT by 14 days old
• Includes: PKU, congenital hypothyroidism, sickle cell, hearing, CCHD, bilirubin, metabolic
disorders
• Congenital Hypothyroidism (CH): Screen within first 4 days of life. CH is the most common
cause of PREVENTABLE mental retardation. Untreated → irreversible brain damage.
• PKU: Deficiency of phenylalanine hydroxylase → phenylalanine accumulates → intellectual
disability if untreated.
• CCHD screening: Pulse oximetry prior to discharge.
, • Hearing screening: Universal by 1 month old — OAE or auditory brainstem response (ABR)
prior to discharge. Repeat if missed.
• Bilirubin: Transcutaneous or serum, prior to discharge.
1.7 Newborn Eye Screening
• Topical ocular prophylaxis (erythromycin ointment) of ALL newborns to prevent ophthalmia
neonatorum (gonorrheal eye infection)
• Red reflex check bilaterally — absent or abnormal = refer immediately for ophthalmology
evaluation (suspect cataract, glaucoma, retinoblastoma)
• Disconjugate gaze: normal in newborns, improving by 2–4 months, resolving by 6 months
1.8 Early Discharge Guidelines
• Hospital stay: minimum 48 hours for vaginal delivery, 96 hours for C-section (Newborns' and
Mothers' Health Protection Act of 1996)
• Follow-up care should occur within 48–72 hours of discharge — assess weight, hydration,
jaundice, feeding, bonding, outstanding labs
• Before discharge: HepB #1, Vitamin K IM, erythromycin eye ointment, newborn screening,
CCHD screening, hearing screening
• Refer to WIC program as appropriate
1.9 Common Neonatal Conditions — Newborn Digestive System and Nutrition
• Jaundice/Hyperbilirubinemia: Physiologic jaundice appears day 2-3, peaks day 3-5, resolves
by 2 weeks. Asian descent: peaks day 4-5. Pathologic = appears within 24 hours, rises rapidly,
persists. Management: phototherapy based on bilirubin level and gestational age.
• Breastfeeding: Recommended exclusively for first 6 months. Breastfed infants need
supplemental Vitamin D 400 IU/day until consuming 32 oz formula/day or fortified milk.
• Cord care: Air dry; diaper below cord. Separation at 10–14 days. Slight bloody discharge 1-2
days after separation is normal. NO alcohol application.
• Colic: Crying >3 hrs/day, >3 days/week, >3 weeks in infants 1–4 months. NORMAL
developmental behavior. PURPLE acronym: Peak/Unexpected/Resists soothing/Pain-like
face/Long-lasting/Evening. No evidence for formula changes or medications.
2. WELL-CHILD VISITS & ANTICIPATORY GUIDANCE
2.1 AAP Well-Child Visit Schedule
Visits are recommended at: birth, 3-5 days, 4 weeks, 2, 4, 6, 9, 12, 15, 18, and 24 months, annually up
to age 6, then every 2 years through adolescence.
Age Group Key Measurements Key Screenings
Newborn / 2-4 Length/weight, head Hearing, vision risk assessment, lead
Months circumference, developmental risk assessment
surveillance, behavioral
assessment, maternal depression
screening
4–6 Months Same as above + immunizations Lead risk assessment, developmental
milestones
9–12 Months Length/weight, head Vision risk, hearing risk, lead risk,
